formulario de medicamentos del año 2018 (lista de...

MEDICARE ADVANTAGE PLANS

Formulario de medicamentos del año 2018 (lista de medicamentos cubiertos)

Presbyterian Senior Care (HMO) Presbyterian Senior Care (HMO-POS) Presbyterian MediCare PPO

Favor de leer: este documento contiene información acerca de los medicamentos que cubre este plan. Aprobación del formulario de medicamentos con presentación de archivo en HPMS núm. 00018142; número de versión 36.

Este formulario de medicamentos se actualizó el 23 de octubre de 2018. Para información más reciente o si tiene otras preguntas, póngase en contacto con el Centro de Servicio al Cliente de Presbyterian al (505) 923 6060 o al 1 800 797 5343 (TTY: 711).

Desde el 1 de octubre hasta el 14 de febrero, el horario de atención es de 8 a. m. a 8 p. m, los siete días de la semana. Desde el 15 de febrero hasta el 30 deseptiembre, el horario de atención es de 8 a. m. a 8 p. m, de lunes a viernes. Cerramos los días festivos.

También puede visitar nuestro sitio web en www.phs.org/Medicare.

Y0055_MPC061765_rev2_Accepted_09092017

http://www.phs.org/Medicare

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Aviso para afiliados existentes: este formulario de medicamentos cambió desde el año pasado. Revise el documento para asegurarse de que se sigan incluyendo los medicamentos que toma.

Cuando esta lista de medicamentos (formulario de medicamentos) hace referencia a “nosotros”, “nos” o “nuestro”, significa Presbyterian Health Plan Inc. y Presbyterian Insurance Company, Inc. Cuando hace referencia a “plan” o “nuestro plan”, significa Presbyterian Senior Care (HMO), Presbyterian Senior Care (HMO-POS) y Presbyterian Medicare PPO. Este documento incluye una lista de medicamentos (formulario de medicamentos) de nuestro plan, la cual está actualizada al 23 de octubre de 2018. Para obtener una lista de medicamentos actualizada, comuníquese con nosotros. La información de contacto, junto con la fecha de la última actualización del formulario de medicamentos, aparecen en la portada y en la contraportada.

En general, debe usar las farmacias de la red para hacer uso de su beneficio de medicamentos recetados. Los beneficios, el formulario de medicamentos, la red de farmacias y/o los copagos/coseguros pueden cambiar el 1 de enero de 2018, y ocasionalmente durante el año.

Presbyterian Senior Care (HMO), Presbyterian Senior Care (HMO-POS) y Presbyterian Medicare PPO son organizaciones de Medicare Advantage que tienen un contrato con Medicare. La inscripción en Presbyterian Senior Care (HMO), en Presbyterian Senior Care (HMO-POS) y en Presbyterian Medicare PPO depende de la renovación del contrato.

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¿Qué es el formulario de medicamentos de Presbyterian Senior Care (HMO), el de Presbyterian Senior Care (HMO- POS) y el de Presbyterian Medicare PPO? Un formulario de medicamentos es una lista de medicamentos cubiertos seleccionados por Presbyterian Senior Care (HMO), por Presbyterian Senior Care (HMO-POS) y por Presbyterian Medicare PPO, bajo la asesoría de un equipo de proveedores de atención médica. Este formulario de medicamentos representa las terapias con medicamentos recetados que se consideran necesarias para un programa de tratamiento de calidad. Por lo general, nuestro plan cubrirá los medicamentos en el formulario de medicamentos siempre y cuando sean médicamente necesarios, se surta la receta en una farmacia de la red de Presbyterian Senior Care (HMO), de Presbyterian Senior Care (HMO-POS) y de Presbyterian Medicare PPO y se sigan las otras reglas de los planes. Para obtener más información sobre cómo surtir sus recetas, consulte su Evidencia de cobertura.

¿Puede cambiar el formulario de medicamentos (lista de medicamentos)? Por lo general, si está tomando un medicamento del formulario de medicamentos del año 2018 que estaba cubierto a principios de año, la cobertura no será interrumpida ni reducida durante el año de cobertura de 2018, a menos que salga a la venta un medicamento genérico más económico o que se dé a conocer nueva información adversa acerca de la seguridad o de la eficacia del medicamento. Los demás tipos de cambios en el formulario de medicamentos, como la eliminación de un medicamento de nuestro formulario de medicamentos, no afectarán a los afiliados que estén tomando el medicamento actualmente. Seguirá estando disponible con el mismo costo compartido para aquellos afiliados que lo tomen durante el resto del año de cobertura. Creemos que es importante que tenga acceso continuo durante el resto del año de cobertura a los medicamentos del formulario que estaban disponibles cuando escogió nuestro plan, excepto en los casos en los que usted pueda ahorrar más dinero o en los que podamos garantizar su seguridad.

Si se eliminan medicamentos del formulario de medicamentos, se agregan requisitos de autorización previa, límites de cantidad o restricciones en las terapias escalonadas para un medicamento o se mueve un medicamento a una categoría más alta de costo compartido, debemos informar a los afiliados afectados acerca del cambio por lo menos 60 días antes de que el cambio entre en vigor, o cuando el afiliado solicite un resurtido del medicamento, momento en el cual el afiliado recibirá un suministro del medicamento para 60 días.

Si la Administración de Medicamentos y Alimentos (Food and Drug Administration) considera que un medicamento de nuestro formulario de medicamentos no es seguro, o si el fabricante del medicamento lo retira del mercado, retiraremos el medicamento del formulario de medicamentos inmediatamente y se lo informaremos a los afiliados que lo estén tomando.

El formulario de medicamentos adjunto está actualizado al 23 de octubre de 2018 . Contáctenos para obtener información actualizada de los medicamentos que nuestro plan cubre. La información de contacto aparece en la portada y en la contraportada. Las actualizaciones mensuales del formulario de medicamentos, como por ejemplo adiciones, eliminaciones, adición de autorización previa, límites de cantidad y/o restricciones a las terapias escalonadas, se publicarán en nuestro sitio web en www.phs.org/Medicare. Si este cambio afecta nuestro formulario de medicamentos de manera negativa y determinamos que este cambio le afecta a usted, le notificaremos por escrito del cambio.

¿Cómo se usa el formulario de medicamentos? Hay dos modos de buscar un medicamento en el formulario de medicamentos:

Problema médico El formulario de medicamentos comienza en la página 9. Los medicamentos en este formulario están agrupados por categoría dependiendo de la clase de problema médico que tratan. Por ejemplo, los


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medicamentos que se usan para tratar problemas cardíacos están bajo la categoría de “agentes cardiovasculares”. Si sabe para qué se usa su medicamento, busque el nombre de la categoría en la lista que comienza en la página 9. Luego, busque el medicamento en dicha categoría.

Listado en orden alfabético Si no está seguro en qué categoría buscar, debe buscar su medicamento en el índice que comienza en la página 114. El índice proporciona una lista en orden alfabético de todos los medicamentos incluidos en este documento. El índice incluye tanto medicamentos de marca como medicamentos genéricos. Consulte el índice y busque su medicamento. A un lado del medicamento, verá el número de la página en la que puede encontrar la información de cobertura. Diríjase a la página indicada en el índice y busque el nombre del medicamento en la primera columna de la lista.

¿Qué son los medicamentos genéricos? Presbyterian Senior Care (HMO), Presbyterian Senior Care (HMO-POS) y Presbyterian MediCare PPO cubren tanto los medicamentos de marca como los medicamentos genéricos. . Un medicamento genérico está aprobado por la FDA porque tiene los mismos ingredientes activos que el medicamento de marca. Por lo general, los medicamentos genéricos cuestan menos que los medicamentos de marca.

¿Existe alguna restricción en mi cobertura? Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites en la cobertura. Estos requisitos y límites pueden incluir:

• Autorización previa: nuestro plan requiere que usted o su médico obtengan autorización previa paraciertos medicamentos. Esto significa que necesitará conseguir la aprobación de nuestro plan antes desurtir su receta. Si no obtiene la aprobación, es posible que el plan no cubra el medicamento.

• Límites de cantidad: para ciertos medicamentos, nuestro plan limita la cantidad de medicamento queel plan cubrirá. Por ejemplo, el plan proporciona 60 (sesenta) cápsulas por receta de duloxetina. Estopuede ser adicional al suministro estándar de un mes o de tres meses.

• Terapia escalonada: en algunos casos, nuestro plan requiere que usted primero pruebe determinadosmedicamentos para tratar su problema médico antes de cubrir otro medicamento para dicho problema.Por ejemplo, si tanto el Medicamento A como el Medicamento B tratan su problema médico, puede serque nuestro plan no cubra el Medicamento B a menos que usted pruebe primero el Medicamento A. Si elMedicamento A no le funciona, entonces el plan cubrirá el Medicamento B.

Para averiguar si su medicamento tiene requerimientos o límites adicionales, consulte el formulario de medicamentos que comienza en la página 9. También puede visitar nuestro sitio web para obtener más información acerca de las restricciones aplicadas a medicamentos cubiertos específicos. Hemos publicado documentos en línea que explican nuestra restricción de autorización previa y las restricciones en las terapias escalonadas. Además, puede solicitarnos que le enviemos una copia. La información de contacto, junto con la fecha de la última actualización del formulario de medicamentos, aparecen en la portada y en la contraportada.

Puede solicitarle a nuestro plan que haga una excepción a estas restricciones o a estos límites, o puede solicitarle una lista de otros medicamentos similares que puedan tratar su problema médico. Consulte la sección “¿Cómo solicito una excepción al formulario de medicamentos de Presbyterian Senior Care (HMO), de Presbyterian Senior Care (HMO-POS) y de Presbyterian Medicare PPO?” en la página 5 para obtener información sobre cómo solicitar una excepción.

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¿Qué hago si mi medicamento no está en el formulario de medicamentos? Si su medicamento no está incluido en este formulario de medicamentos (lista de medicamentos cubiertos), primero debe comunicarse con Servicio al Cliente y preguntar si el medicamento está cubierto.

Si se le informa que nuestro plan no cubre el medicamento, tiene dos opciones:

• Puede solicitar en Servicio al Cliente una lista de medicamentos similares que estén cubiertos pornuestro plan. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamentosimilar que esté cubierto por el plan.

• Puede solicitarles a Presbyterian Senior Care (HMO), a Presbyterian Senior Care (HMO-POS) y aPresbyterian Medicare PPO que hagan una excepción y cubran el medicamento. Consulte acontinuación la información sobre cómo solicitar una excepción.

¿Cómo les solicito una excepción a Presbyterian Senior Care (HMO), a Presbyterian Senior Care (HMO-POS) y a Presbyterian Medicare PPO? Puede solicitarle a nuestro plan que haga una excepción a las reglas de cobertura. Puede solicitarnos varios tipos de excepciones.

• Puede solicitarnos que cubramos un medicamento, aunque no esté en el formulario de medicamentos. Si seaprueba, este medicamento estará cubierto a una categoría de costo compartido predeterminada y usted nopodrá solicitarnos que proporcionemos este medicamento a una categoría de costo compartido inferior.

• Puede solicitarnos que cubramos un medicamento del formulario a una categoría de costo compartidoinferior si este medicamento no está en la categoría de especialidades. Si se aprueba, esto reduciría elmonto que debe pagar por el medicamento.

• Puede solicitar que no apliquemos los límites o las restricciones de cobertura al medicamento. Porejemplo: para ciertos medicamentos, nuestro plan limita la cantidad de medicamento que cubriremos.Si el medicamento tiene un límite de cantidad, puede solicitarnos que no apliquemos el límite y quecubramos una mayor cantidad.

Por lo general, nuestro plan solo aprobará su solicitud de excepción si los medicamentos alternativos que se incluyen en el formulario de medicamentos del plan, el medicamento de menor costo compartido o las restricciones de utilización adicionales no son tan efectivos para tratar su problema médico o le causan efectos médicos adversos.

Debe comunicarse con nosotros para solicitar una decisión de cobertura inicial para obtener una excepción al formulario de medicamentos, a la categoría o a las restricciones de utilización. Al solicitar una excepción al formulario de medicamentos, a la categoría o a las restricciones de utilización, debe presentar una declaración de su recetador o de su médico donde se respalde su solicitud. Generalmente, debemos tomar una decisión en el plazo de 72 horas después de haber recibido la declaración de respaldo del recetador. Puede solicitar una excepción acelerada (rápida) si usted o su médico creen que su salud podría sufrir un daño grave con una espera de hasta 72 horas por una decisión. Si se le otorga la solicitud acelerada, debemos tomar una decisión a más tardar 24 horas después de haber recibido la declaración de respaldo del médico o del otro recetador.

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¿Qué hago antes de poder hablar con mi médico sobre el cambio de medicamentos o sobre la solicitud de una excepción? Como afiliado nuevo o existente de nuestro plan, es posible que esté tomando medicamentos que no están en el formulario de medicamentos. O bien, quizá esté tomando un medicamento que está en el formulario de medicamentos, pero su capacidad de conseguirlo es limitada. Por ejemplo, es posible que necesite de una autorización previa para poder surtir su receta. Debe hablar con su médico para decidir si debe cambiar a un medicamento apropiado que cubramos, o para solicitar una excepción al formulario de medicamentos para que cubramos el medicamento que está tomando. Mientras habla con su médico para determinar cuál es el curso de acción adecuado, es posible que, en determinados casos, cubramos el medicamento durante los primeros 90 días de su afiliación en nuestro plan.

Para cada medicamento que no esté en nuestro formulario de medicamentos, o si su capacidad de conseguir sus medicamentos es limitada, cubriremos un suministro temporal por 30 días (a menos que la receta se haya hecho para menos días) cuando vaya a una farmacia de la red. Después del primer suministro de 30 días, no pagaremos estos medicamentos, aunque usted haya sido afiliado del plan por menos de 90 días.

Si es residente de un centro de atención a largo plazo, le permitiremos resurtir la receta hasta que le hayamos proporcionado un suministro de transición para al menos 91 días, conforme con el incremento de dispensación en un ámbito de atención a largo plazo (a menos que su receta se haya hecho para menos días). Cubriremos más de un resurtido de estos medicamentos durante los primeros 90 días de su afiliación en el plan. Si necesita un medicamento que no está en nuestro formulario de medicamentos o su capacidad de conseguir sus medicamentos es limitada, pero ya transcurrieron los primeros 90 días de su afiliación en el plan, cubriremos un suministro de emergencia del medicamento para 31 días (a menos que su receta se haya hecho para menos días) mientras usted trata de obtener una excepción al formulario de medicamentos. Si se produce un cambio en el nivel de su atención, tal como un cambio de un centro de atención a largo plazo a un entorno domiciliario o del hospital a un entorno domiciliario, y usted necesita un medicamento que no está en nuestro formulario de medicamentos o si su capacidad de conseguir los medicamentos es limitada, nosotros le cubriremos un suministro temporal por única vez. Este suministro temporal es para hasta 31 días, a menos que la receta se haya hecho para menos de 31 días. Durante este período, usted deberá utilizar el proceso de excepciones del plan si desea seguir teniendo cobertura para el medicamento después de que se le termine el suministro temporal.

Para obtener más información Para obtener más información detallada sobre la cobertur a de medicamentos recetados de Presbyterian Senior Care (HMO), de Presbyterian Senio r Care (HMO-POS) y de Presbyterian Medicare PPO, lea detenidam ente la Evidencia de cobertura y los demás materiales del plan.

Contáctenos si tiene preguntas sobre nuestro plan. La información de contacto, junto con la fecha de la última actualización del formulario de medicamentos, aparecen en la portada y en la contraportada.

Si tiene preguntas generales sobre la cobertura de medicamentos recetados de Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227), las 24 horas del día, los 7 días de la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O bien, visite http://www.medicare.gov.

http://www.medicare.gov/

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Formulario de medicamentos de Presbyterian Senior Care (HMO), de Presbyterian Senior Care (HMO- POS), y de Presbyterian Medicare PPO El siguiente formulario de medicamentos proporciona información sobre los medicamentos cubiertos por Presbyterian Senior Care (HMO), por Presbyterian Senior Care (HMO-POS) y por Presbyterian Medicare PPO. Si tiene problemas para encontrar su medicamento en la lista, consulte el índice que comienza en la página 114.

La primera columna del cuadro muestra los nombres de los medicamentos. Los medicamentos de marca están en mayúsculas (por ej., LYRICA), y los medicamentos genéricos aparecen en letra cursiva en minúsculas (por. ej., lisinopril).

La información en la columna “Requerimientos/Límites” le indica si su plan tiene algún requisito especial para la cobertura del medicamento.

Explicación de los niveles de clasificación de los medicamentos Los medicamentos de receta se clasifican en uno de cinco niveles: Nivel 1, Nivel 2, Nivel 3, Nivel 4 o Nivel 5. La Administración de Medicamentos y Alimentos [FDA por sus siglas en inglés] aprueba un medicamento genérico por tener los mismos ingredientes activos que el medicamento de marca. Por lo general, los medicamentos genéricos cuestan menos que los medicamentos de marca. Si usted desea averiguar las cantidades de copagos o coseguro por cada nivel de medicamentos, consulte la Evidencia de Cobertura del 2018.

• Nivel 1 - Medicamentos genéricos que favorece el plan: Medicamentos genéricos o de marca que están asu disposición al costo compartido más bajo de este plan

• Nivel 2 - Medicamentos genéricos: Medicamentos genéricos o de marca que el plan le ofrece a un costomás alto que los medicamentos genéricos que favorece el plan del Nivel 1

• Nivel 3 - Medicamentos de marca: Medicamentos genéricos o de marca que el plan le ofrece a un costomás bajo que los medicamentos de marca que no favorece el plan del Nivel 4

• Nivel 4 - Medicamentos que no favorece el plan: Medicamentos genéricos o de marca que el plan leofrece a un costo más alto que los medicamentos de marca que favorece el plan del Nivel 3

• Nivel 5 – Nivel especializado: Algunos medicamentos inyectables y otros medicamentos de costoelevado

¿Cuánto pagaré por los medicamentos cubiertos? La cantidad de dinero que pague dependerá de:

• La categoría de medicamento en la que está su medicamento en el formulario de medicamentos.

• Su actual etapa de pago de medicamentos: lea la Evidencia de cobertura (EOC) para más información.

Si calificó para Ayuda Adicional con los costos de medicamentos, sus costos pueden ser distintos. Consulte la Evidencia de cobertura (EOC) o el Anexo LIS, o llame a Servicio al Cliente para averiguar cuáles son sus costos.

Explicación de abreviaturas

Abreviatura Significado PA B/D Este medicamento puede estar cubierto por la Parte B o por la Parte D de

Medicare según las circunstancias. Puede ser necesario presentar información que describa el uso y la configuración del medicamento para tomar la determinación.

GC Brecha de Cobertura. Ofrecemos cobertura de este medicamento recetado en la brecha de cobertura. Consulte la Evidencia de cobertura para obtener más información sobre esta cobertura.

LA Acceso limitado. Este medicamento recetado podría estar disponible solo en ciertas farmacias. Para obtener más información, consulte su Directorio de farmacias o llame al Centro de Servicio al Cliente de Presbyterian al (505) 923-7675 o al 1-855-465-7737 (TTY: 711).

Desde el 1 de octubre hasta el 14 de febrero, el horario de atención es de 8 a. m. a 8 p. m, los 7 días de la semana. Del 15 de febrero al 30 de septiembre, el horario de atención es de 8 a. m. a 8 p. m., de lunes a viernes (a excepción de los días festivos).

PA Autorización previa. Usted o su médico deben obtener una autorización previa antes de surtir su receta para este medicamento. Sin aprobación previa, es posible que no cubramos este medicamento.

QL Límites de cantidad. Hay un límite en la cantidad de este medicamento que se cubrirá por receta, o en un plazo de tiempo específico.

ST Terapia escalonada. En algunos casos, es posible que se le requiera que primero pruebe determinados medicamentos para tratar su problema médico antes de cubrir otro medicamento para dicho problema.

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Nombre del medicamento Nivel del medicamento

Requisitos/Limites

Agentes Antiespasticidad Agentes Antiespasticidad

baclofen oral tablet 10 mg, 20 mg 2 GC

tizanidine hcl oral tablet 2 mg, 4 mg 2 GC

Agentes Antigota Agentes Antigota

allopurinol oral tablet 100 mg, 300 mg 1 GC

COLCHICINE ORAL TABLET 0.6 MG 3

colchicine-probenecid oral tablet 0.5-500 mg 2 GC

probenecid oral tablet 500 mg 2 GC

ULORIC ORAL TABLET 40 MG, 80 MG 4 QL (1 EA per 1 day)

Agentes Antiinflamatorios Glucocorticoides

betamethasone dipropionate external lotion 0.05 %

2 GC

dexamethasone oral tablet 0.75 mg 2 GC

hydrocortisone ace-pramoxine rectal cream 1-1 % 4

Medicamentos Antiinflamatorios No Esteroideos diclofenac potassium oral tablet 50 mg 1 GC

ibu oral tablet 400 mg 1 GC

ibu oral tablet 600 mg, 800 mg 1 GC

ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 GC

Agentes Antimiasténicos Parasimpaticomiméticos

guanidine hcl oral tablet 125 mg 4

MESTINON ORAL SYRUP 60 MG/5ML 3

pyridostigmine bromide oral tablet 60 mg 2 GC

Agentes Antimigraña Agonistas De Los Receptores De Serotonina (5-Ht) 1B/1D

En la página 8 puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla.

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Requisitos/Limites

almotriptan malate oral tablet 12.5 mg, 6.25 mg 4 ST; QL (18 EA per 30 days)

frovatriptan succinate oral tablet 2.5 mg 4 ST; QL (18 EA per 30 days)

naratriptan hcl oral tablet 1 mg, 2.5 mg 2 ST; GC; QL (18 EA per 30 days)

rizatriptan benzoate oral tablet 10 mg, 5 mg 4 ST; QL (18 EA per 30 days)

rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg

4 ST; QL (18 EA per 30 days)

SUMATRIPTAN NASAL SOLUTION 20 MG/ACT

3 QL (12 EA per 30 days)

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg

2 GC; QL (18 EA per 30 days)

sumatriptan succinate refill subcutaneous solution cartridge 4 mg/0.5ml

2 GC; QL (4 ML per 30 days)

sumatriptan succinate refill subcutaneous solution cartridge 6 mg/0.5ml


sumatriptan succinate subcutaneous solution 6 mg/0.5ml


sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml


sumatriptan succinate subcutaneous solution auto-injector 6 mg/0.5ml


sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml


zolmitriptan oral tablet 2.5 mg, 5 mg 2 ST; GC; QL (18 EA per 30 days)

Alcaloides Del Ergot dihydroergotamine mesylate injection solution 1 mg/ml

2 GC

DIHYDROERGOTAMINE MESYLATE NASAL SOLUTION 4 MG/ML

5 QL (8 ML per 28 days)

ergotamine-caffeine oral tablet 1-100 mg 3

Agentes Antiparkinsonianos Agentes Antiparkinsonianos


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Requisitos/Limites

carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg

2 GC

Agentes Antiparkinsonianos, Otros entacapone oral tablet 200 mg 4

tolcapone oral tablet 100 mg 5

Agonistas De La Dopamina APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 MG/3ML

4 PA; LA

bromocriptine mesylate oral capsule 5 mg 2 GC

bromocriptine mesylate oral tablet 2.5 mg 2 GC

NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR

4 QL (1 EA per 1 day)

pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg

2 GC

ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg

2 GC

Anticolinérgicos benztropine mesylate injection solution 1 mg/ml 2 GC

benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg

2 GC

trihexyphenidyl hcl oral elixir 0.4 mg/ml 2 GC

trihexyphenidyl hcl oral tablet 2 mg, 5 mg 2 GC

Inhibidores De La Monoamino Oxidasa B (Mao-B) rasagiline mesylate oral tablet 0.5 mg, 1 mg 4 QL (1 EA per 1 day)

selegiline hcl oral capsule 5 mg 2 GC

selegiline hcl oral tablet 5 mg 2 GC

Precursores De La Dopamina/Inhibidores De La Descarboxilasa De L- Aminoácidos carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg

1 GC


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Requisitos/Limites

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg

1 GC

Agentes Cardiovasculares Agentes Bloqueadores Adrenérgicos Alfa

doxazosin mesylate oral tablet 1 mg 1 GC

prazosin hcl oral capsule 1 mg, 2 mg, 5 mg 1 GC

Agentes Bloqueadores Adrenérgicos Beta acebutolol hcl oral capsule 200 mg, 400 mg 2 GC

atenolol oral tablet 100 mg, 25 mg, 50 mg 1 GC

betaxolol hcl oral tablet 10 mg, 20 mg 2 GC

bisoprolol fumarate oral tablet 10 mg, 5 mg 2 GC

BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG

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carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg

1 GC

labetalol hcl intravenous solution 5 mg/ml 2 GC

labetalol hcl oral tablet 100 mg, 200 mg, 300 mg 2 GC

metoprolol succinate er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 50 mg

1 GC

metoprolol tartrate intravenous solution 5 mg/5ml 2 GC

metoprolol tartrate intravenous solution cartridge 5 mg/5ml

2 GC

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

1 GC

nadolol oral tablet 20 mg, 40 mg, 80 mg 2 GC

pindolol oral tablet 10 mg, 5 mg 2 GC

propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg

2 GC

propranolol hcl intravenous solution 1 mg/ml 2 GC

PROPRANOLOL HCL ORAL SOLUTION 20 MG/5ML, 40 MG/5ML

3

propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

1 GC


12


Requisitos/Limites

TIMOLOL MALEATE ORAL TABLET 10 MG, 20 MG, 5 MG

3

Agentes Bloqueadores De Los Canales De Calcio AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG

3

amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg

2 GC

CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG

3

diltiazem cd oral capsule extended release 24 hour 120 mg, 180 mg

2 GC

diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

2 GC

diltiazem hcl er beads oral capsule extended release 24 hour 360 mg, 420 mg

2 GC

diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg

2 GC

diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg

2 GC

diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

2 GC

diltiazem hcl intravenous solution 50 mg/10ml 2 GC

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg

2 GC

dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

2 GC

felodipine er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg

2 GC

nicardipine hcl oral capsule 20 mg, 30 mg 2 GC

nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg

2 GC

nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg

2 GC


13


Requisitos/Limites

nimodipine oral capsule 30 mg 2 GC

NISOLDIPINE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 20 MG, 30 MG, 40 MG

3

TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG

3

verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg

2 GC

verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg

2 GC

verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 2 GC

Agentes Cardiovasculares ALDACTAZIDE ORAL TABLET 50-50 MG 4

amiloride-hydrochlorothiazide oral tablet 5-50 mg 2 GC

amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg

2 GC

atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg

2 GC

benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

1 GC

bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg

1 GC

candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, 32-25 mg

4 ST

captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg

1 GC

DEMSER ORAL CAPSULE 250 MG 5

enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg

1 GC

ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg

3 ST

fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg

1 GC


14


Requisitos/Limites

lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

1 GC

losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg

2 GC

metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 mg, 50-25 mg

2 GC

moexipril-hydrochlorothiazide oral tablet 15-12.5 mg, 15-25 mg, 7.5-12.5 mg

1 GC

PROPRANOLOL-HCTZ ORAL TABLET 40-25 MG, 80-25 MG

3

quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

1 GC

spironolactone-hctz oral tablet 25-25 mg 2 GC

triamterene-hctz oral capsule 37.5-25 mg 2 GC

triamterene-hctz oral capsule 50-25 mg 2 GC

triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg 2 GC

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

2 ST; GC

Agentes Cardiovasculares, Otros CORLANOR ORAL TABLET 5 MG, 7.5 MG 4 PA; QL (2 EA per 1 day)

DIGITEK ORAL TABLET 125 MCG, 250 MCG 3

digox oral tablet 125 mcg, 250 mcg 1 GC

digoxin oral solution 0.05 mg/ml 1 GC

digoxin oral tablet 125 mcg, 250 mcg 1 GC

pentoxifylline er oral tablet extended release 400 mg

2 GC

RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG, 500 MG


REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE 420 MG/3.5ML

5 PA

UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

5 PA; QL (2 EA per 1 day)


15


Requisitos/Limites

UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 MCG

5 PA; QL (400 EA per 365 days)

Agonistas Adrenérgicos Alfa clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 2 GC

clonidine hcl transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr


guanfacine hcl oral tablet 1 mg, 2 mg 2 GC

midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg 2 GC

NORTHERA ORAL CAPSULE 100 MG 5 PA; QL (3 EA per 1 day)

NORTHERA ORAL CAPSULE 200 MG, 300 MG


Antagonistas De Los Receptores De Angiotensina Ii candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg

4 ST

ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG


irbesartan oral tablet 150 mg, 300 mg, 75 mg 2 GC

losartan potassium oral tablet 100 mg, 25 mg, 50 mg

2 GC

olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg

4 ST

olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, 40-25 mg

4 ST

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg

4 ST

Antiarrítmicos amiodarone hcl intravenous solution 150 mg/3ml 2 GC

amiodarone hcl intravenous solution 450 mg/9ml 2 GC

amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg

2 GC

DOFETILIDE ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG

3

flecainide acetate oral tablet 100 mg, 150 mg, 50 mg

2 GC


16


Requisitos/Limites

mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg

2 GC

MULTAQ ORAL TABLET 400 MG 4 QL (2 EA per 1 day)

PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG

3

propafenone hcl oral tablet 150 mg, 225 mg, 300 mg

2 GC

quinidine gluconate er oral tablet extended release 324 mg

2 GC

quinidine sulfate oral tablet 200 mg, 300 mg 2 GC

SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG

3

sotalol hcl (af) oral tablet 120 mg 2 GC

sotalol hcl oral tablet 120 mg 2 GC

sotalol hcl oral tablet 160 mg, 240 mg, 80 mg 2 GC

Dislipidemias, Derivados Del Ácido Fíbrico fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

2 GC

fenofibrate oral tablet 160 mg, 54 mg 2 GC

gemfibrozil oral tablet 600 mg 2 GC

Dislipidemias, Inhibidores De La Hmg Coa Reductasa atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg

2 GC

lovastatin oral tablet 10 mg, 20 mg, 40 mg 1 GC

pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg

1 GC

rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg

2 GC

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg

1 GC

Dislipidemias, Otros cholestyramine light oral packet 4 gm 2 GC

cholestyramine light oral powder 4 gm/dose 2 GC


17


Requisitos/Limites

cholestyramine oral packet 4 gm 2 GC

cholestyramine oral powder 4 gm/dose 2 GC

colestipol hcl oral granules 5 gm 2 GC

colestipol hcl oral packet 5 gm 2 GC

colestipol hcl oral tablet 1 gm 2 GC

ezetimibe oral tablet 10 mg 1 GC

JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG

5 PA; LA

KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML

5 PA; LA; QL (4 ML per 28 days)

niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 500 mg, 750 mg

4

omega-3-acid ethyl esters oral capsule 1 gm 4 QL (4 EA per 1 day)

PREVALITE ORAL PACKET 4 GM 3

PREVALITE ORAL POWDER 4 GM/DOSE 3

REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 140 MG/ML

5 PA

REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML

5 PA

triklo oral capsule 1 gm 4 QL (4 EA per 1 day)

VASCEPA ORAL CAPSULE 1 GM 4 QL (4 EA per 1 day)

WELCHOL ORAL PACKET 3.75 GM 3

WELCHOL ORAL TABLET 625 MG 3

Diuréticos De Asa bumetanide injection solution 0.25 mg/ml 2 GC

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 2 GC

ethacrynate sodium intravenous solution reconstituted 50 mg

3

ethacrynic acid oral tablet 25 mg 3

furosemide injection solution 10 mg/ml, 10 mg/ml (4ml syringe)

2 GC

FUROSEMIDE ORAL SOLUTION 8 MG/ML 3


18


Requisitos/Limites

furosemide oral tablet 20 mg, 40 mg, 80 mg 1 GC

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 2 GC

Diuréticos, Ahorradores De Potasio amiloride hcl oral tablet 5 mg 2 GC

DYRENIUM ORAL CAPSULE 100 MG, 50 MG 3

eplerenone oral tablet 25 mg, 50 mg 2 GC

spironolactone oral tablet 100 mg, 25 mg, 50 mg 1 GC

Diuréticos, Inhibidores De La Anhidrasa Carbónica acetazolamide oral tablet 125 mg, 250 mg 2 GC

methazolamide oral tablet 25 mg, 50 mg 2 GC

Diuréticos, Tiazida chlorothiazide oral tablet 250 mg, 500 mg 2 GC

chlorthalidone oral tablet 25 mg, 50 mg 2 GC

hydrochlorothiazide oral capsule 12.5 mg 1 GC

hydrochlorothiazide oral tablet 12.5 mg 2 GC

hydrochlorothiazide oral tablet 25 mg, 50 mg 1 GC

indapamide oral tablet 1.25 mg, 2.5 mg 2 GC

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg

2 GC

METHYCLOTHIAZIDE ORAL TABLET 5 MG 3

metolazone oral tablet 10 mg, 2.5 mg, 5 mg 2 GC

Inhibidores De La Enzima Convertidora De Angiotensina (Ace, Por Sus Siglas En Ingles) benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg

1 GC

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg

1 GC

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

1 GC

fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg 1 GC

lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg

1 GC


19


Requisitos/Limites

moexipril hcl oral tablet 15 mg, 7.5 mg 1 GC

quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg

1 GC

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg

1 GC

Vasodilatadores, Acción Directa Arterial hydralazine hcl injection solution 20 mg/ml 2 GC

hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

2 GC

minoxidil oral tablet 10 mg, 2.5 mg 2 GC

Vasodilatadores, Acción Directa Arterial/Venosa isosorbide dinitrate er oral tablet extended release 40 mg

2 GC

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg

2 GC

isosorbide mononitrate er oral tablet extended release 24 hour 120 mg, 30 mg, 60 mg

2 GC

isosorbide mononitrate oral tablet 10 mg, 20 mg 2 GC

MINITRAN TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR

3

NITRO-BID TRANSDERMAL OINTMENT 2 % 3

NITROGLYCERIN INTRAVENOUS SOLUTION 5 MG/ML

3

nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg

1 GC

nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

2 GC

Agentes Contra La Bipolaridad Estabilizadores Del Estado De Ánimo

carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg

2 GC

lithium carbonate er oral tablet extended release 300 mg, 450 mg

2 GC


20


Requisitos/Limites

lithium carbonate oral capsule 150 mg, 300 mg, 600 mg

2 GC

LITHIUM ORAL SOLUTION 8 MEQ/5ML 3

Agentes Contra La Demencia Agentes Contra La Demencia, Otros

ergoloid mesylates oral tablet 1 mg 2 GC

Inhibidores De La Colinesterasa donepezil hcl oral tablet 10 mg 2 GC; QL (2 EA per 1 day)

donepezil hcl oral tablet 5 mg 2 GC; QL (1 EA per 1 day)

donepezil hcl oral tablet dispersible 10 mg 2 GC; QL (2 EA per 1 day)

donepezil hcl oral tablet dispersible 5 mg 2 GC; QL (1 EA per 1 day)

galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 mg

2 GC; QL (1 EA per 1 day)

galantamine hydrobromide er oral capsule extended release 24 hour 8 mg


galantamine hydrobromide oral solution 4 mg/ml 2 GC

galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg

2 GC

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg


rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr

4

Receptor Antagonista N-Metil-D-Aspartato (Nmda) memantine hcl oral tablet 10 mg, 5 (28)-10 (21) mg, 5 mg

2 GC

Agentes Del Trastorno Del Sueño Moduladores Del Receptor Gaba

eszopiclone oral tablet 1 mg, 2 mg, 3 mg 4 QL (90 EA per 365 days)

flurazepam hcl oral capsule 15 mg, 30 mg 2 GC; QL (1 EA per 1 day)

temazepam oral capsule 15 mg 2 GC; QL (2 EA per 1 day)

temazepam oral capsule 30 mg 2 GC; QL (1 EA per 1 day)

zaleplon oral capsule 10 mg, 5 mg 2 GC; QL (90 EA per 365 days)


21


Requisitos/Limites

zolpidem tartrate er oral tablet extended release 12.5 mg, 6.25 mg


zolpidem tartrate oral tablet 10 mg, 5 mg 2 GC; QL (90 EA per 365 days)

Trastornos Del Sueño, Otros ARMODAFINIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50 MG


BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG

4 ST; QL (1 EA per 1 day)

HETLIOZ ORAL CAPSULE 20 MG 5 PA; LA; QL (1 EA per 1 day)

ROZEREM ORAL TABLET 8 MG 4 PA; QL (1 EA per 1 day)

XYREM ORAL SOLUTION 500 MG/ML 5 PA; QL (540 ML per 30 days)

Agentes Dentales Y Bucales Agentes Dentales Y Orales

cevimeline hcl oral capsule 30 mg 4

chlorhexidine gluconate mouth/throat solution 0.12 %

2 GC

oralone mouth/throat paste 0.1 % 2 GC

paroex mouth/throat solution 0.12 % 2 GC

PERIOGARD MOUTH/THROAT SOLUTION 0.12 %

3

pilocarpine hcl oral tablet 5 mg 2 GC

triamcinolone acetonide mouth/throat paste 0.1 % 2 GC

Agentes Dermatológicos Agentes Dermatológicos

acitretin oral capsule 10 mg, 17.5 mg, 25 mg 5

amlactin external lotion 12 % 2 GC

ammonium lactate external lotion 12 % 2 GC

avita external cream 0.025 % 4

AZELEX EXTERNAL CREAM 20 % 3

benzoyl peroxide-erythromycin external gel 5-3 % 2 GC

calcipotriene external cream 0.005 % 4


22


Requisitos/Limites

calcipotriene external solution 0.005 % 4

claravis oral capsule 10 mg, 20 mg, 40 mg 4

CLARAVIS ORAL CAPSULE 30 MG 4

clindamycin phos-benzoyl perox external gel 1-5 %

2 GC

clobetasol propionate external solution 0.05 % 2 GC

clotrimazole-betamethasone external cream 1-0.05 %

4

clotrimazole-betamethasone external lotion 1-0.05 %

4

CORMAX SCALP APPLICATION EXTERNAL SOLUTION 0.05 %

3

diclofenac sodium transdermal gel 1 % 4

diclofenac sodium transdermal gel 3 % 5

doxepin hcl external cream 5 % 4

FINACEA EXTERNAL FOAM 15 % 3

FINACEA EXTERNAL GEL 15 % 3

FLUOROURACIL EXTERNAL CREAM 0.5 % 3

fluorouracil external cream 5 % 4

fluorouracil external solution 2 %, 5 % 2 GC

imiquimod external cream 5 % 4

methoxsalen rapid oral capsule 10 mg 4

myorisan oral capsule 10 mg, 20 mg, 30 mg, 40 mg

4

nystatin-triamcinolone external cream 100000-0.1 unit/gm-%

2 GC

nystatin-triamcinolone external ointment 100000-0.1 unit/gm-%

2 GC

podofilox external solution 0.5 % 2 GC

PRUDOXIN EXTERNAL CREAM 5 % 4

REGRANEX EXTERNAL GEL 0.01 % 3

SANTYL EXTERNAL OINTMENT 250 UNIT/GM

4


23


Requisitos/Limites

selenium sulfide external lotion 2.5 % 2 GC

tacrolimus external ointment 0.03 % 4 PA; QL (100 GM per 60 days)

tacrolimus external ointment 0.1 % 4 PA; QL (120 GM per 60 days)

tazarotene external cream 0.1 % 4

TAZORAC EXTERNAL CREAM 0.05 % 4

TAZORAC EXTERNAL GEL 0.05 %, 0.1 % 4

tretinoin external cream 0.025 %, 0.05 %, 0.1 % 4

UVADEX INJECTION SOLUTION 20 MCG/ML 4

zenatane oral capsule 10 mg, 20 mg, 40 mg 4

ZENATANE ORAL CAPSULE 30 MG 4

Agentes Gastrointestinales Agentes Gastrointestinales, Otros

DIPHENOXYLATE-ATROPINE ORAL LIQUID 2.5-0.025 MG/5ML

3 PA

diphenoxylate-atropine oral tablet 2.5-0.025 mg 2 PA; GC

GATTEX SUBCUTANEOUS KIT 5 MG 5 PA; LA; QL (1 EA per 1 day)

loperamide hcl oral capsule 2 mg 2 GC

metoclopramide hcl injection solution 5 mg/ml 2 GC

metoclopramide hcl oral solution 5 mg/5ml 2 GC

metoclopramide hcl oral tablet 10 mg, 5 mg 2 GC

MOVANTIK ORAL TABLET 12.5 MG, 25 MG 4 PA; QL (1 EA per 1 day)

RELISTOR ORAL TABLET 150 MG 5 PA; QL (3 EA per 1 day)

RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML, 12 MG/0.6ML (0.6ML SYRINGE)

5 PA; QL (0.6 ML per 1 day)

RELISTOR SUBCUTANEOUS SOLUTION 8 MG/0.4ML

5 PA; QL (0.8 ML per 1 day)

ursodiol oral capsule 300 mg 2 GC

ursodiol oral tablet 250 mg, 500 mg 2 GC

XERMELO ORAL TABLET 250 MG 5 PA; LA; QL (3 EA per 1 day)

Agentes Para El Síndrome De Intestino Irritable alosetron hcl oral tablet 0.5 mg, 1 mg 4 QL (2 EA per 1 day)


24


Requisitos/Limites

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG 3 QL (2 EA per 1 day)

budesonide er oral tablet extended release 24 hour 9 mg

5

budesonide oral capsule delayed release particles 3 mg

5

LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG


Antagonistas De Los Receptores De Histamina 2 (H2) cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg

2 GC

famotidine intravenous solution 20 mg/2ml 2 GC

famotidine intravenous solution 200 mg/20ml 2 GC

famotidine oral tablet 20 mg, 40 mg 2 GC

nizatidine oral capsule 150 mg, 300 mg 2 GC

nizatidine oral solution 15 mg/ml 2 GC

ranitidine hcl injection solution 50 mg/2ml 2 GC

ranitidine hcl oral syrup 75 mg/5ml 2 GC

ranitidine hcl oral tablet 150 mg, 300 mg 1 GC

Antiespasmódicos, Gastrointestinales dicyclomine hcl intramuscular solution 10 mg/ml 2 PA; GC

dicyclomine hcl oral capsule 10 mg 2 PA; GC

dicyclomine hcl oral solution 10 mg/5ml 2 PA; GC

dicyclomine hcl oral tablet 20 mg 2 PA; GC

glycopyrrolate injection solution 4 mg/20ml 2 GC

glycopyrrolate oral tablet 1 mg, 2 mg 2 GC

Inhibidores De La Bomba De Protones DEXILANT ORAL CAPSULE DELAYED RELEASE 30 MG, 60 MG


lansoprazole oral capsule delayed release 15 mg, 30 mg


omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg



25


Requisitos/Limites

pantoprazole sodium intravenous solution reconstituted 40 mg

2 GC

pantoprazole sodium oral tablet delayed release 20 mg, 40 mg


rabeprazole sodium oral tablet delayed release 20 mg


Laxantes constulose oral solution 10 gm/15ml 2 GC

enulose oral solution 10 gm/15ml 2 GC

GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240 GM

3

GAVILYTE-G ORAL SOLUTION RECONSTITUTED 236 GM

3

GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 420 GM

3

generlac oral solution 10 gm/15ml 2 GC

GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM

3

KRISTALOSE ORAL PACKET 10 GM, 20 GM 4

lactulose encephalopathy oral solution 10 gm/15ml

2 GC

lactulose oral solution 10 gm/15ml 2 GC

peg 3350/electrolytes oral solution reconstituted 240 gm

2 GC

peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm

2 GC

peg-3350/electrolytes oral solution reconstituted 236 gm

2 GC

polyethylene glycol 3350 oral powder 2 GC

TRILYTE ORAL SOLUTION RECONSTITUTED 420 GM

3

Protectores CARAFATE ORAL SUSPENSION 1 GM/10ML 4

misoprostol oral tablet 100 mcg, 200 mcg 2 GC


26


Requisitos/Limites

sucralfate oral tablet 1 gm 2 GC

Agentes Genitourinarios Agentes Genitourinarios, Otros

bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg

2 GC

CUPRIMINE ORAL CAPSULE 250 MG 3

ELMIRON ORAL CAPSULE 100 MG 4

potassium citrate er oral tablet extended release 10 meq (1080 mg), 5 meq (540 mg)

2 GC

sodium phenylbutyrate oral powder 3 gm/tsp 5 PA

Agentes Para Hipertrofia Prostática Benigna alfuzosin hcl er oral tablet extended release 24 hour 10 mg

4 ST

doxazosin mesylate oral tablet 2 mg, 4 mg, 8 mg 1 GC

dutasteride oral capsule 0.5 mg 2 GC

finasteride oral tablet 5 mg 2 GC

tamsulosin hcl oral capsule 0.4 mg 2 GC

terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 GC

Aglutinantes De Fosfato calcium acetate (phos binder) oral capsule 667 mg 2 GC

sevelamer carbonate oral packet 0.8 gm, 2.4 gm 3

sevelamer carbonate oral tablet 800 mg 3

Antiespasmódicos, Urinarios flavoxate hcl oral tablet 100 mg 2 GC

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 25 MG, 50 MG


oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg, 5 mg

2 GC

oxybutynin chloride oral syrup 5 mg/5ml 2 GC

oxybutynin chloride oral tablet 5 mg 2 GC

tolterodine tartrate er oral capsule extended release 24 hour 2 mg, 4 mg



27


Requisitos/Limites

tolterodine tartrate oral tablet 1 mg, 2 mg 2 GC

trospium chloride er oral capsule extended release 24 hour 60 mg


trospium chloride oral tablet 20 mg 2 GC

VESICARE ORAL TABLET 10 MG, 5 MG 4 ST; QL (1 EA per 1 day)

Agentes Hormonales, Estimulantes/Reemplazo/Modificadores (Adrenales) Agentes Hormonales, Estimulantes/Reemplazo/Modificadores (Adrenales)

ala-cort external cream 1 %, 2.5 % 2 GC

alclometasone dipropionate external cream 0.05 %

2 GC

alclometasone dipropionate external ointment 0.05 %

2 GC

AMCINONIDE EXTERNAL OINTMENT 0.1 % 4

betamethasone dipropionate aug external cream 0.05 %

2 GC

betamethasone dipropionate aug external gel 0.05 %

2 GC

betamethasone dipropionate aug external lotion 0.05 %

2 GC

betamethasone dipropionate aug external ointment 0.05 %

2 GC

betamethasone dipropionate external cream 0.05 %

2 GC

betamethasone dipropionate external ointment 0.05 %

2 GC

betamethasone valerate external cream 0.1 % 2 GC

betamethasone valerate external lotion 0.1 % 2 GC

betamethasone valerate external ointment 0.1 % 2 GC

clobetasol propionate e external cream 0.05 % 2 GC

clobetasol propionate external cream 0.05 % 2 GC

clobetasol propionate external gel 0.05 % 2 GC

clobetasol propionate external ointment 0.05 % 2 GC


28


Requisitos/Limites

CORTISONE ACETATE ORAL TABLET 25 MG

3

deltasone oral tablet 20 mg 2 GC

desoximetasone external cream 0.05 %, 0.25 % 4

desoximetasone external gel 0.05 % 4

desoximetasone external ointment 0.25 % 4

DEXAMETHASONE INTENSOL ORAL CONCENTRATE 1 MG/ML

3

dexamethasone oral elixir 0.5 mg/5ml 2 GC

dexamethasone oral tablet 0.5 mg, 1.5 mg, 4 mg, 6 mg

2 GC

DEXAMETHASONE ORAL TABLET 1 MG, 2 MG

3

dexamethasone sod phosphate pf injection solution 10 mg/ml

2 GC

dexamethasone sodium phosphate injection solution 10 mg/ml, 120 mg/30ml

2 GC

fludrocortisone acetate oral tablet 0.1 mg 2 GC

fluocinolone acetonide body external oil 0.01 % 2 GC

fluocinolone acetonide external cream 0.01 %, 0.025 %

2 GC

fluocinolone acetonide external ointment 0.025 % 2 GC

fluocinolone acetonide external solution 0.01 % 4

fluocinolone acetonide otic oil 0.01 % 2 GC

fluocinolone acetonide scalp external oil 0.01 % 2 GC

fluocinonide emulsified base external cream 0.05 %

2 GC

fluocinonide external cream 0.05 % 2 GC

fluocinonide external gel 0.05 % 2 GC

fluocinonide external ointment 0.05 % 2 GC

fluocinonide external solution 0.05 % 2 GC

fluocinonide-e external cream 0.05 % 2 GC

fluticasone propionate external cream 0.05 % 2 GC


29


Requisitos/Limites

fluticasone propionate external ointment 0.005 % 2 GC

halobetasol propionate external cream 0.05 % 2 GC

hydrocortisone butyr lipo base external cream 0.1 %

2 GC

hydrocortisone butyrate external cream 0.1 % 2 GC

hydrocortisone butyrate external ointment 0.1 % 2 GC

hydrocortisone butyrate external solution 0.1 % 2 GC

hydrocortisone external cream 1 %, 2.5 % 2 GC

hydrocortisone external lotion 2.5 % 2 GC

hydrocortisone external ointment 1 %, 2.5 % 2 GC

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg 2 GC

hydrocortisone rectal cream 1 % 2 GC

hydrocortisone valerate external cream 0.2 % 2 GC

methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg

2 GC

methylprednisolone oral tablet therapy pack 4 mg 2 GC

methylprednisolone sodium succ injection solution reconstituted 1000 mg, 125 mg

2 GC

mometasone furoate external cream 0.1 % 2 GC

mometasone furoate external ointment 0.1 % 2 GC

mometasone furoate external solution 0.1 % 2 GC

prednisolone oral solution 15 mg/5ml 2 GC

prednisolone oral syrup 15 mg/5ml 2 GC

prednisolone sodium phosphate oral solution 15 mg/5ml

2 GC

prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml

2 GC

PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML

3

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg

2 GC

PREDNISONE ORAL TABLET 50 MG 3


30


Requisitos/Limites

prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), 5 mg (21), 5 mg (48)

2 GC

PROCTOFOAM HC RECTAL FOAM 1-1 % 3

PROCTO-PAK RECTAL CREAM 1 % 3

SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 2 GM

4

triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 %

2 GC

triamcinolone acetonide external lotion 0.025 %, 0.1 %

2 GC

triamcinolone acetonide external ointment 0.025 %, 0.1 %

2 GC

TRIAMCINOLONE ACETONIDE EXTERNAL OINTMENT 0.5 %

3

TRIDERM EXTERNAL CREAM 0.1 % 3

triderm external cream 0.5 % 2 GC

Agentes Hormonales, Estimulantes/Reemplazo/Modificadores (Hormonas Sexuales/Modificadores)

Agentes Hormonales, Estimulantes/Reemplazo/Modificadores (Hormonas Sexuales/Modificadores)

desogestrel-ethinyl estradiol oral tablet 0.15-30 mg-mcg

2 GC

ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg

2 GC

isibloom oral tablet 0.15-30 mg-mcg 2 GC

lillow oral tablet 0.15-30 mg-mcg 2 GC

lopreeza oral tablet 0.5-0.1 mg, 1-0.5 mg 4 PA

Agentes Modificadores Selectivos De Los Receptores De Estrógeno raloxifene hcl oral tablet 60 mg 2 GC

Andrógenos ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24HR, 4 MG/24HR



31


Requisitos/Limites

ANDROGEL PUMP TRANSDERMAL GEL 20.25 MG/ACT (1.62%)

3 PA; QL (150 GM per 30 days)

ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%)


ANDROGEL TRANSDERMAL GEL 40.5 MG/2.5GM (1.62%)


ANDROXY ORAL TABLET 10 MG 4

danazol oral capsule 100 mg, 200 mg, 50 mg 2 GC

testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

2 PA; GC

testosterone enanthate intramuscular solution 200 mg/ml

2 PA; GC

Esteroides Anabólicos ANADROL-50 ORAL TABLET 50 MG 5

oxandrolone oral tablet 10 mg, 2.5 mg 2 GC

Estrógenos ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR

4 PA

ALTAVERA ORAL TABLET 0.15-30 MG-MCG 3

ALYACEN 1/35 ORAL TABLET 1-35 MG-MCG 3

ALYACEN 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG

3

AMABELZ ORAL TABLET 0.5-0.1 MG, 1-0.5 MG

4 PA

AMETHIA LO ORAL TABLET 0.1-0.02 & 0.01 MG

3

APRI ORAL TABLET 0.15-30 MG-MCG 3

ARANELLE ORAL TABLET 0.5/1/0.5-35 MG-MCG

3

aubra eq oral tablet 0.1-20 mg-mcg 3

AUBRA ORAL TABLET 0.1-20 MG-MCG 3

AVIANE ORAL TABLET 0.1-20 MG-MCG 3


32


Requisitos/Limites

azurette oral tablet 0.15-0.02/0.01 mg (21/5) 2 GC

BEKYREE ORAL TABLET 0.15-0.02/0.01 MG (21/5)

3

BLISOVI FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

3

BLISOVI FE 1/20 ORAL TABLET 1-20 MG-MCG

3

CAMRESE LO ORAL TABLET 0.1-0.02 & 0.01 MG

3

CAZIANT ORAL TABLET 0.1/0.125/0.15 -0.025 MG

3

chateal eq oral tablet 0.15-30 mg-mcg 3

CHATEAL ORAL TABLET 0.15-30 MG-MCG 3

COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY

4 PA

CRYSELLE-28 ORAL TABLET 0.3-30 MG-MCG

3

CYCLAFEM 1/35 ORAL TABLET 1-35 MG-MCG

3

CYCLAFEM 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG

3

CYRED ORAL TABLET 0.15-30 MG-MCG 3

DASETTA 1/35 ORAL TABLET 1-35 MG-MCG 3

DASETTA 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG

3

DELYLA ORAL TABLET 0.1-20 MG-MCG 3

desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5)

2 GC

DROSPIREN-ETH ESTRAD-LEVOMEFOL ORAL TABLET 3-0.02-0.451 MG

4

DROSPIRENONE-ETHINYL ESTRADIOL ORAL TABLET 3-0.02 MG, 3-0.03 MG

3

ELINEST ORAL TABLET 0.3-30 MG-MCG 3


33


Requisitos/Limites

EMOQUETTE ORAL TABLET 0.15-30 MG-MCG

3

ENPRESSE-28 ORAL TABLET 3

ENSKYCE ORAL TABLET 0.15-30 MG-MCG 3

ESTARYLLA ORAL TABLET 0.25-35 MG-MCG

3

estradiol oral tablet 0.5 mg, 1 mg, 2 mg 4 PA

estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

4 PA

estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

4 PA

estradiol vaginal cream 0.1 mg/gm 3

estradiol vaginal tablet 10 mcg 3

estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg

4 PA

ESTRING VAGINAL RING 2 MG 4

estropipate oral tablet 0.75 mg, 1.5 mg 4 PA

ESTROPIPATE ORAL TABLET 3 MG 4 PA

EVAMIST TRANSDERMAL SOLUTION 1.53 MG/SPRAY

4 PA

FALMINA ORAL TABLET 0.1-20 MG-MCG 3

FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 MG/24HR

4

FEMYNOR ORAL TABLET 0.25-35 MG-MCG 3

fyavolv oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg 4 PA

GIANVI ORAL TABLET 3-0.02 MG 3

GILDESS FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

3

GILDESS FE 1/20 ORAL TABLET 1-20 MG-MCG

3

INTRAROSA VAGINAL INSERT 6.5 MG 4 PA

INTROVALE ORAL TABLET 0.15-0.03 MG 3


34


Requisitos/Limites

jevantique lo oral tablet 0.5-2.5 mg-mcg 4 PA

jinteli oral tablet 1-5 mg-mcg 4 PA

JOLESSA ORAL TABLET 0.15-0.03 MG 3

JULEBER ORAL TABLET 0.15-30 MG-MCG 3

JUNEL 1.5/30 ORAL TABLET 1.5-30 MG-MCG 3

JUNEL 1/20 ORAL TABLET 1-20 MG-MCG 3

JUNEL FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

3

JUNEL FE 1/20 ORAL TABLET 1-20 MG-MCG 3

KARIVA ORAL TABLET 0.15-0.02/0.01 MG (21/5)

3

KELNOR 1/35 ORAL TABLET 1-35 MG-MCG 3

KIMIDESS ORAL TABLET 0.15-0.02/0.01 MG (21/5)

3

KURVELO ORAL TABLET 0.15-30 MG-MCG 3

LARIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG 3

LARIN 1/20 ORAL TABLET 1-20 MG-MCG 3

LARIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

3

LARIN FE 1/20 ORAL TABLET 1-20 MG-MCG 3

LARISSIA ORAL TABLET 0.1-20 MG-MCG 3

LEENA ORAL TABLET 0.5/1/0.5-35 MG-MCG 3

LESSINA ORAL TABLET 0.1-20 MG-MCG 3

LEVONEST ORAL TABLET 3

LEVONORGEST-ETH ESTRAD 91-DAY ORAL TABLET 0.1-0.02 & 0.01 MG

3

levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg

2 GC

LEVONORGESTREL-ETHINYL ESTRAD ORAL TABLET 0.1-20 MG-MCG, 0.15-30 MG-MCG

3

levonorg-eth estrad triphasic oral tablet 2 GC


35


Requisitos/Limites

LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 MG-MCG

3

LORYNA ORAL TABLET 3-0.02 MG 3

LOW-OGESTREL ORAL TABLET 0.3-30 MG-MCG

3

LUTERA ORAL TABLET 0.1-20 MG-MCG 3

MARLISSA ORAL TABLET 0.15-30 MG-MCG 3

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG

3 PA

MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG

3

MICROGESTIN 1/20 ORAL TABLET 1-20 MG-MCG

3

MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG

3

MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG

3

mili oral tablet 0.25-35 mg-mcg 3

mimvey lo oral tablet 0.5-0.1 mg 4 PA

mimvey oral tablet 1-0.5 mg 4 PA

MONO-LINYAH ORAL TABLET 0.25-35 MG-MCG

3

MONONESSA ORAL TABLET 0.25-35 MG-MCG

3

myzilra oral tablet 2 GC

NECON 1/50 (28) ORAL TABLET 1-50 MG-MCG

3

NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG

3

NIKKI ORAL TABLET 3-0.02 MG 3

NORETHIN ACE-ETH ESTRAD-FE ORAL TABLET 1-20 MG-MCG

3

norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg

2 GC


36


Requisitos/Limites

norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

4 PA

NORGESTIMATE-ETH ESTRADIOL ORAL TABLET 0.25-35 MG-MCG

3

norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-35 mcg

2 GC

NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG

3

NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG

3

NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG

3

NUVARING VAGINAL RING 0.12-0.015 MG/24HR

4

OCELLA ORAL TABLET 3-0.03 MG 3

ORSYTHIA ORAL TABLET 0.1-20 MG-MCG 3

OSPHENA ORAL TABLET 60 MG 4 PA

PIMTREA ORAL TABLET 0.15-0.02/0.01 MG (21/5)

3

PIRMELLA 1/35 ORAL TABLET 1-35 MG-MCG

3

PIRMELLA 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG

3

PORTIA-28 ORAL TABLET 0.15-30 MG-MCG 3

PREFEST ORAL TABLET 1/1-0.09 MG (15/15) 4 PA

PREMARIN INJECTION SOLUTION RECONSTITUTED 25 MG

3

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG

3 PA

PREMARIN VAGINAL CREAM 0.625 MG/GM 3

PREMPHASE ORAL TABLET 0.625-5 MG 3 PA

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG

3 PA

PREVIFEM ORAL TABLET 0.25-35 MG-MCG 3


37


Requisitos/Limites

QUASENSE ORAL TABLET 0.15-0.03 MG 3

RECLIPSEN ORAL TABLET 0.15-30 MG-MCG 3

SETLAKIN ORAL TABLET 0.15-0.03 MG 3

SPRINTEC 28 ORAL TABLET 0.25-35 MG-MCG

3

SRONYX ORAL TABLET 0.1-20 MG-MCG 3

SYEDA ORAL TABLET 3-0.03 MG 3

TARINA FE 1/20 ORAL TABLET 1-20 MG-MCG

3

TILIA FE ORAL TABLET 1-20/1-30/1-35 MG-MCG

3

TRI FEMYNOR ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

3

TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

3

TRI-LEGEST FE ORAL TABLET 1-20/1-30/1-35 MG-MCG

3

TRI-LINYAH ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

3

tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg 3

TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

3

TRI-PREVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

3

TRI-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG

3

TRIVORA (28) ORAL TABLET 3

tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg 3

VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025 MG

3

VESTURA ORAL TABLET 3-0.02 MG 3

VIENVA ORAL TABLET 0.1-20 MG-MCG 3

viorele oral tablet 0.15-0.02/0.01 mg (21/5) 2 GC

vylibra oral tablet 0.25-35 mg-mcg 3


38


Requisitos/Limites

xulane transdermal patch weekly 150-35 mcg/24hr 4

YUVAFEM VAGINAL TABLET 10 MCG 3

ZARAH ORAL TABLET 3-0.03 MG 3

ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG

3

Progesterona Agonistas/Antagonistas ELLA ORAL TABLET 30 MG 3

Progestinas BALZIVA ORAL TABLET 0.4-35 MG-MCG 3

BRIELLYN ORAL TABLET 0.4-35 MG-MCG 3

CAMILA ORAL TABLET 0.35 MG 3

DEBLITANE ORAL TABLET 0.35 MG 3

ERRIN ORAL TABLET 0.35 MG 3

GILDAGIA ORAL TABLET 0.4-35 MG-MCG 3

HEATHER ORAL TABLET 0.35 MG 3

incassia oral tablet 0.35 mg 2

JENCYCLA ORAL TABLET 0.35 MG 3

JOLIVETTE ORAL TABLET 0.35 MG 3

LYZA ORAL TABLET 0.35 MG 3

medroxyprogesterone acetate intramuscular suspension 150 mg/ml

2 GC

medroxyprogesterone acetate intramuscular suspension prefilled syringe 150 mg/ml

2 GC

medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg

2 GC

megestrol acetate oral suspension 40 mg/ml 2 GC

megestrol acetate oral suspension 625 mg/5ml 4

megestrol acetate oral tablet 20 mg, 40 mg 2 GC

NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG

3

NORA-BE ORAL TABLET 0.35 MG 3

norethindrone acetate oral tablet 5 mg 2 GC En la página 8 puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla.

39


Requisitos/Limites

norethindrone oral tablet 0.35 mg 2 GC

NORLYDA ORAL TABLET 0.35 MG 3

NORLYROC ORAL TABLET 0.35 MG 3

NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG

3

PHILITH ORAL TABLET 0.4-35 MG-MCG 3

progesterone micronized oral capsule 100 mg, 200 mg

2 GC

SHAROBEL ORAL TABLET 0.35 MG 3

VYFEMLA ORAL TABLET 0.4-35 MG-MCG 3

WERA ORAL TABLET 0.5-35 MG-MCG 3

ZENCHENT ORAL TABLET 0.4-35 MG-MCG 3

Agentes Hormonales, Estimulantes/Reemplazo/Modificadores (Pituitaria) Agentes Hormonales, Estimulantes/Reemplazo/Modificadores (Pituitaria)

desmopressin ace rhinal tube nasal solution 0.01 %

2 GC

desmopressin ace spray refrig nasal solution 0.01 %

2 GC

desmopressin acetate injection solution 4 mcg/ml 2 GC

desmopressin acetate oral tablet 0.1 mg, 0.2 mg 2 GC

INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML

5 PA; LA

OMNITROPE SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 5 MG/1.5ML

5 PA; LA

OMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTED 5.8 MG

5 PA; LA

Agentes Hormonales, Estimulantes/Reemplazo/Modificadores (Tiroides) Agentes Hormonales, Estimulantes/Reemplazo/Modificadores (Tiroides)

ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG

3


40


Requisitos/Limites

levo-t oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

2 GC

levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

1 GC

levothyroxine-liothyronine oral tablet 120 mg, 15 mg, 30 mg

3

LEVOTHYROXINE-LIOTHYRONINE ORAL TABLET 60 MG, 90 MG

3

LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

3

liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg

2 GC

NP THYROID ORAL TABLET 120 MG, 15 MG, 30 MG, 60 MG, 90 MG

3

SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

4

UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

3

Agentes Hormonales, Supresores (Adrenales) Agentes Hormonales, Supresores (Adrenales)

LYSODREN ORAL TABLET 500 MG 3

Agentes Hormonales, Supresores (Paratiroides) Agentes Hormonales, Supresores (Paratiroides)

doxercalciferol intravenous solution 4 mcg/2ml 4

doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg

4

SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG

3


41


Requisitos/Limites

Agentes Hormonales, Supresores (Pituitaria) Agentes Hormonales, Supresores (Pituitaria)

cabergoline oral tablet 0.5 mg 2 GC

ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 MG

4

ELIGARD SUBCUTANEOUS KIT 7.5 MG 3

FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG, 80 MG

4

leuprolide acetate injection kit 1 mg/0.2ml 2 GC

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG, 7.5 MG

5

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG, 22.5 MG

5

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30 MG

5

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45 MG

5

LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG

5

LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 11.25 MG (PED)

5

octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml, 50 mcg/ml

2 GC

octreotide acetate injection solution 1000 mcg/ml, 500 mcg/ml

5

SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML

5 PA; QL (2 ML per 1 day)

SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML

5 PA

SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30 MG

5

SYNAREL NASAL SOLUTION 2 MG/ML 5 PA


42


Requisitos/Limites

Agentes Hormonales, Supresores (Tiroides) Agentes Antitiroideos

methimazole oral tablet 10 mg, 5 mg 2 GC

propylthiouracil oral tablet 50 mg 2 GC

Agentes Inmunológicos Agentes De Angioedema (Hae)

BERINERT INTRAVENOUS KIT 500 UNIT 5 PA; LA

CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT

5 PA; LA

FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML

5 PA; LA

Agentes Inmunizadores, Pasivos GAMASTAN S/D INTRAMUSCULAR INJECTABLE , (10ML), (2ML)

3 PA B/D

GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 5 GM/50ML

4 PA

HIZENTRA SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML

5 PA

HYPERRAB S/D INJECTION SOLUTION 1500 UNIT/10ML, 300 UNIT/2ML

3

HYPERRAB S/D INTRAMUSCULAR INJECTABLE 150 UNIT/ML

3

IMOGAM RABIES-HT INJECTION SOLUTION 300 UNIT/2ML

3

IMOGAM RABIES-HT INTRAMUSCULAR INJECTABLE 150 UNIT/ML

3

SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5ML

5

THYMOGLOBULIN INTRAVENOUS SOLUTION RECONSTITUTED 25 MG

5

Inmunomoduladores


43


Requisitos/Limites

ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 UNIT/0.5ML

5 LA

ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED 220 MG

5 PA; LA

ILARIS (150MG DELIVERED) SUBCUTANEOUS SOLUTION RECONSTITUTED 180 MG

5 PA; LA

ILARIS SUBCUTANEOUS SOLUTION 150 MG/ML

5 PA; LA

leflunomide oral tablet 10 mg, 20 mg 2 GC

RIDAURA ORAL CAPSULE 3 MG 4

SYLVANT INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

5 PA

Supresores Inmunológicos ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 162 MG/0.9ML

5 PA; QL (3.6 ML per 28 days)

AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG

5 PA

azathioprine oral tablet 50 mg 2 PA B/D; GC

BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED 120 MG, 400 MG

5 PA; LA

BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/ML


BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML


cyclosporine intravenous solution 50 mg/ml 2 PA B/D; GC

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg

2 PA B/D; GC

cyclosporine modified oral solution 100 mg/ml 2 PA B/D; GC

cyclosporine oral capsule 100 mg, 25 mg 2 PA B/D; GC

ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML

5 PA

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML



44


Requisitos/Limites

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML

5 PA

ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG


ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML

5 PA

GENGRAF ORAL CAPSULE 100 MG, 25 MG, 50 MG

3 PA B/D

GENGRAF ORAL SOLUTION 100 MG/ML 3 PA B/D

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 40 MG/0.8ML (6 PACK), 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

5 PA

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML, 40 MG/0.8ML

5 PA

HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML

5 PA

HUMIRA PEN-PS/UV STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

5 PA

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.4ML, 40 MG/0.8ML

5 PA

KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.67ML

5 PA

mercaptopurine oral tablet 50 mg 2 GC

methotrexate oral tablet 2.5 mg 1 GC

methotrexate sodium (pf) injection solution 1 gm/40ml

2 GC

methotrexate sodium (pf) injection solution 250 mg/10ml, 50 mg/2ml

2 GC

methotrexate sodium injection solution 250 mg/10ml

2 GC

methotrexate sodium injection solution 50 mg/2ml 2 GC


45


Requisitos/Limites

methotrexate sodium injection solution reconstituted 1 gm

4

mycophenolate mofetil hcl intravenous solution reconstituted 500 mg

4 PA B/D

mycophenolate mofetil oral capsule 250 mg 2 PA B/D; GC

mycophenolate mofetil oral suspension reconstituted 200 mg/ml

5 PA B/D

mycophenolate mofetil oral tablet 500 mg 2 PA B/D; GC

mycophenolate sodium oral tablet delayed release 180 mg, 360 mg

4 PA B/D

NULOJIX INTRAVENOUS SOLUTION RECONSTITUTED 250 MG

5 PA

ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 125 MG/ML

5 PA; QL (4 ML per 28 days)

ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML


OTEZLA ORAL TABLET 30 MG 5 PA; LA; QL (2 EA per 1 day)

OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 MG

5 PA; LA; QL (2 EA per 1 day)

PROGRAF INTRAVENOUS SOLUTION 5 MG/ML

4 PA B/D

RAPAMUNE ORAL SOLUTION 1 MG/ML 4 PA B/D

REMICADE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

5 PA

SANDIMMUNE ORAL SOLUTION 100 MG/ML 4 PA B/D

sirolimus oral tablet 0.5 mg, 1 mg 4 PA B/D

sirolimus oral tablet 2 mg 5 PA B/D

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg 2 PA B/D; GC

XATMEP ORAL SOLUTION 2.5 MG/ML 4 PA

XELJANZ ORAL TABLET 10 MG, 5 MG 5 PA; QL (2 EA per 1 day)

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG


ZORTRESS ORAL TABLET 0.25 MG 4 PA B/D; QL (2 EA per 1 day)


46


Requisitos/Limites

ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG 5 PA B/D; QL (2 EA per 1 day)

Vacunas ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED

3

ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 (PREFILLED SYRINGE), 5-2-15.5 LF-MCG/0.5

3

BCG VACCINE INJECTION INJECTABLE 3

BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

3

BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 , 5-2.5-18.5 (0.5ML SYRINGE)

3

DAPTACEL INTRAMUSCULAR SUSPENSION 10-15-5 , 15-23-5 LF-MCG/0.5

3

DIPHTHERIA-TETANUS TOXOIDS DT INTRAMUSCULAR SUSPENSION 25-5 LFU/0.5ML

3

ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 10 MCG/0.5ML (0.5ML SYRINGE), 20 MCG/ML

3 PA B/D

GARDASIL 9 INTRAMUSCULAR SUSPENSION

3

GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

3

HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML, 1440 EL U/ML 1 ML, 720 EL U/0.5ML, 720 EL U/0.5ML 0.5 ML

3

HIBERIX INJECTION SOLUTION RECONSTITUTED 10 MCG

3

IMOVAX RABIES INTRAMUSCULAR INJECTABLE 2.5 UNIT/ML

3

INFANRIX INTRAMUSCULAR SUSPENSION 25-58-10

3

IPOL INJECTION INJECTABLE 3

IXIARO INTRAMUSCULAR SUSPENSION 3


47


Requisitos/Limites

KINRIX INTRAMUSCULAR SUSPENSION , INJECTION 0.5 ML

3

MENACTRA INTRAMUSCULAR INJECTABLE

3

MENOMUNE SUBCUTANEOUS INJECTABLE 3

MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED

3

M-M-R II SUBCUTANEOUS INJECTABLE 3

PEDIARIX INTRAMUSCULAR SUSPENSION 3

PEDVAX HIB INTRAMUSCULAR SUSPENSION 7.5 MCG/0.5ML

3

PROQUAD SUBCUTANEOUS INJECTABLE 3

QUADRACEL INTRAMUSCULAR SUSPENSION

3

RABAVERT INTRAMUSCULAR SUSPENSION RECONSTITUTED

3

RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 10 MCG/ML (1ML SYRINGE), 40 MCG/ML, 5 MCG/0.5ML

3 PA B/D

ROTARIX ORAL SUSPENSION RECONSTITUTED

3

ROTATEQ ORAL SOLUTION 3

SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG

3

TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU

3

TETANUS-DIPHTHERIA TOXOIDS TD INTRAMUSCULAR SUSPENSION 2-2 LF/0.5ML

3

TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

3

TWINRIX INTRAMUSCULAR SUSPENSION 720-20

3

TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5ML, 25 MCG/0.5ML (0.5ML SYRINGE)

3


48


Requisitos/Limites

VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 25 UNIT/0.5ML 0.5 ML, 50 UNIT/ML, 50 UNIT/ML 1 ML

3

VARIVAX SUBCUTANEOUS INJECTABLE 1350 PFU/0.5ML

3

VARIZIG INTRAMUSCULAR SOLUTION 125 UNIT/1.2ML

5 PA

YF-VAX SUBCUTANEOUS INJECTABLE 3

ZOSTAVAX SUBCUTANEOUS SUSPENSION RECONSTITUTED 19400 UNT/0.65ML

3

Agentes Oftalmológicos Agentes Antialérgicos Oftálmicos

ALOCRIL OPHTHALMIC SOLUTION 2 % 3

ALOMIDE OPHTHALMIC SOLUTION 0.1 % 3

azelastine hcl ophthalmic solution 0.05 % 2 GC

cromolyn sodium ophthalmic solution 4 % 2 GC

EMADINE OPHTHALMIC SOLUTION 0.05 % 4 ST

epinastine hcl ophthalmic solution 0.05 % 2 GC

olopatadine hcl ophthalmic solution 0.1 % 4

Agentes Oftalmológicos bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 %

2 GC

BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 %

3

BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 %

3

neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000

2 GC

neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-0.1

2 GC

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

2 GC

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

2 GC


49


Requisitos/Limites

NEOMYCIN-POLYMYXIN-HC OPHTHALMIC SUSPENSION 3.5-10000-1

3

neo-polycin hc ophthalmic ointment 1 % 2 GC

polymyxin b-trimethoprim ophthalmic solution 10000-0.1 unit/ml-%

2 GC

tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 %

2 GC

Agentes Oftalmológicos Antiglaucoma ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %

3

apraclonidine hcl ophthalmic solution 0.5 % 2 GC

AZOPT OPHTHALMIC SUSPENSION 1 % 3

betaxolol hcl ophthalmic solution 0.5 % 2 GC

BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 %

3

brimonidine tartrate ophthalmic solution 0.15 %, 0.2 %

2 GC

carteolol hcl ophthalmic solution 1 % 2 GC

COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 %

4

dorzolamide hcl ophthalmic solution 2 % 2 GC

dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml

2 GC

levobunolol hcl ophthalmic solution 0.5 % 2 GC

methazolamide oral tablet 25 mg, 50 mg 2 GC

metipranolol ophthalmic solution 0.3 % 2 GC

PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.125 %

3

SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 %

4

timolol maleate ophthalmic solution 0.25 %, 0.5 % 2 GC

timolol maleate ophthalmic solution 0.5 % (daily) 4

Agentes Oftalmológicos, Otros


50


Requisitos/Limites

atropine sulfate ophthalmic solution 1 % 2 GC

bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm

2 GC

CYSTARAN OPHTHALMIC SOLUTION 0.44 %

5 PA

LACRISERT OPHTHALMIC INSERT 5 MG 3

neo-polycin ophthalmic ointment 3.5-400-10000 2 GC

polycin ophthalmic ointment 500-10000 unit/gm 2 GC

RESTASIS MULTIDOSE OPHTHALMIC EMULSION 0.05 %

3 QL (16.5 ML per 90 days)

RESTASIS OPHTHALMIC EMULSION 0.05 % 3 QL (2 EA per 1 day)

Análogos Oftalmológicos De Las Prostaglandinas Y Prostamidas latanoprost ophthalmic solution 0.005 % 2 GC

LUMIGAN OPHTHALMIC SOLUTION 0.01 % 3

TRAVATAN Z OPHTHALMIC SOLUTION 0.004 %

3

Antiinflamatorios Oftálmicos ALREX OPHTHALMIC SUSPENSION 0.2 % 3

diclofenac sodium ophthalmic solution 0.1 % 2 GC

DUREZOL OPHTHALMIC EMULSION 0.05 % 4 ST

fluorometholone ophthalmic suspension 0.1 % 2 GC

flurbiprofen sodium ophthalmic solution 0.03 % 2 GC

FML FORTE OPHTHALMIC SUSPENSION 0.25 %

3

FML OPHTHALMIC OINTMENT 0.1 % 3

ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 %

2 GC

LOTEMAX OPHTHALMIC GEL 0.5 % 4

LOTEMAX OPHTHALMIC SUSPENSION 0.5 %

4

prednisolone acetate ophthalmic suspension 1 % 2 GC


51


Requisitos/Limites

PREDNISOLONE SODIUM PHOSPHATE OPHTHALMIC SOLUTION 1 %

3

XIIDRA OPHTHALMIC SOLUTION 5 % 4 PA; QL (2 EA per 1 day)

Agentes Óticos Agentes Óticos

ACETASOL HC OTIC SOLUTION 2-1 % 3

COLY-MYCIN S OTIC SUSPENSION 3.3-3-10-0.5 MG/ML

3

hydrocortisone-acetic acid otic solution 1-2 % 2 GC

neomycin-polymyxin-hc otic solution 1 % 2 GC

neomycin-polymyxin-hc otic suspension 3.5-10000-1

2 GC

Agentes Para El Sistema Nervioso Central Agentes De La Esclerosis Múltiple

AMPYRA ORAL TABLET EXTENDED RELEASE 12 HOUR 10 MG


AUBAGIO ORAL TABLET 14 MG, 7 MG 5 PA; LA; QL (1 EA per 1 day)

AVONEX INTRAMUSCULAR KIT 30 MCG 5

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT 30 MCG/0.5ML

5

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML

5

dalfampridine er oral tablet extended release 12 hour 10 mg


EXTAVIA SUBCUTANEOUS KIT 0.3 MG 5 PA

glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ml

5 QL (1 ML per 1 day)

glatiramer acetate subcutaneous solution prefilled syringe 40 mg/ml


glatopa subcutaneous solution prefilled syringe 20 mg/ml

5 QL (1 ML per 1 day)

glatopa subcutaneous solution prefilled syringe 40 mg/ml



52


Requisitos/Limites

OCREVUS INTRAVENOUS SOLUTION 300 MG/10ML

5 PA; LA

REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML


REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 6X8.8 & 6X22 MCG


REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 22 MCG/0.5ML, 44 MCG/0.5ML


REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6X8.8 & 6X22 MCG


TYSABRI INTRAVENOUS CONCENTRATE 300 MG/15ML

5 PA; LA

Agentes De Trastorno Por Déficit De Atención E Hiperactividad, No Anfetaminas atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg


dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg


dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg


guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 mg, 3 mg, 4 mg


METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG


methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg


methylphenidate hcl er oral tablet extended release 10 mg, 20 mg


methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 54 mg


methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 54 mg



53


Requisitos/Limites

methylphenidate hcl er oral tablet extended release 24 hour 36 mg


methylphenidate hcl er oral tablet extended release 36 mg


methylphenidate hcl er tablet extended release 27 mg oral 27 mg






methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg


Agentes Del Trastorno Por Déficit De Atención Con Hiperactividad, Anfetaminas amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg


amphetamine-dextroamphet er oral capsule extended release 24 hour 20 mg, 25 mg, 30 mg


amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg


dexedrine oral tablet 10 mg, 5 mg 2 GC; QL (6 EA per 1 day)

dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg






dextroamphetamine sulfate oral tablet 10 mg, 5 mg 2 GC; QL (6 EA per 1 day)

VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG


ZENZEDI ORAL TABLET 10 MG, 5 MG 3 QL (6 EA per 1 day)

Sistema Nervioso Central, Otros AUSTEDO ORAL TABLET 12 MG 5 PA; QL (4 EA per 1 day)

AUSTEDO ORAL TABLET 6 MG, 9 MG 5 PA; QL (1 EA per 1 day)

NUEDEXTA ORAL CAPSULE 20-10 MG 4 QL (2 EA per 1 day)


54


Requisitos/Limites

riluzole oral tablet 50 mg 2 GC

tetrabenazine oral tablet 12.5 mg 5 PA; QL (3 EA per 1 day)

tetrabenazine oral tablet 25 mg 5 PA; QL (4 EA per 1 day)

Agentes Para El Tracto Respiratorio/Pulmones Agentes Para El Tracto Respiratorio, Otros

acetylcysteine inhalation solution 10 %, 20 % 2 PA B/D; GC

ESBRIET ORAL TABLET 267 MG 5 PA; QL (6 EA per 1 day)

ESBRIET ORAL TABLET 801 MG 5 PA; QL (3 EA per 1 day)

LUMIZYME INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

5 PA; LA

PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG

5 LA

ribavirin inhalation solution reconstituted 6 gm 5

STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT

3

Agentes Para El Tracto Respiratorio/Pulmones COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION 20-100 MCG/ACT

4 QL (8 GM per 30 days)

ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml

2 PA B/D; GC

OFEV ORAL CAPSULE 100 MG, 150 MG 5 PA; LA; QL (2 EA per 1 day)

SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT

3 ST

XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 MG

5 PA; LA

Agentes Para La Fibrosis Quística CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG

5 PA

KALYDECO ORAL PACKET 50 MG, 75 MG 5 PA; QL (2 EA per 1 day)

KALYDECO ORAL TABLET 150 MG 5 PA; QL (2 EA per 1 day)

ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG



55


Requisitos/Limites

PULMOZYME INHALATION SOLUTION 1 MG/ML

5 PA B/D

SYMDEKO ORAL TABLET THERAPY PACK 100-150 & 150 MG


TOBI PODHALER INHALATION CAPSULE 28 MG

5

Antihipertensivos Pulmonares ADCIRCA ORAL TABLET 20 MG 5 PA; QL (2 EA per 1 day)

ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG


LETAIRIS ORAL TABLET 10 MG, 5 MG 5 LA; QL (1 EA per 1 day)

OPSUMIT ORAL TABLET 10 MG 5 PA; LA; QL (1 EA per 1 day)

REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML

5 PA B/D; LA

sildenafil citrate oral tablet 20 mg 2 PA; GC; QL (3 EA per 1 day)

tadalafil (pah) oral tablet 20 mg 5 PA; QL (2 EA per 1 day)

TRACLEER ORAL TABLET 125 MG, 62.5 MG 5 LA; QL (2 EA per 1 day)

VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 MCG/ML

5 PA B/D; QL (3 ML per 1 day)

Antihistamínicos azelastine hcl nasal solution 0.1 % 2 GC

cetirizine hcl oral solution 1 mg/ml 2 GC

cetirizine hcl oral syrup 1 mg/ml 2 GC

cyproheptadine hcl oral syrup 2 mg/5ml 2 GC

cyproheptadine hcl oral tablet 4 mg 2 GC

diphenhydramine hcl injection solution 50 mg/ml 2 GC

levocetirizine dihydrochloride oral tablet 5 mg 2 GC

promethazine hcl injection solution 25 mg/ml, 50 mg/ml

2 GC

promethazine hcl oral syrup 6.25 mg/5ml 2 GC

promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg

2 GC


56


Requisitos/Limites

Antiinflamatorios, Corticosteroides Inhalados ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE

4 ST

ADVAIR HFA INHALATION AEROSOL 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT

4 ST

ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH

3

ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH

3

ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH

3

ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 MCG/ACT

3

budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, 1 mg/2ml

2 PA B/D; GC

budesonide nasal suspension 32 mcg/act 4

FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST

3

FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT

3

flunisolide nasal solution 25 mcg/act (0.025%) 2 GC

fluticasone propionate nasal suspension 50 mcg/act

2 GC

FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT

4 ST

mometasone furoate nasal suspension 50 mcg/act 4


57


Requisitos/Limites

PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT

4

QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT

4

QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT

4

Antileucotrienos montelukast sodium oral tablet 10 mg 2 GC; QL (1 EA per 1 day)

montelukast sodium oral tablet chewable 4 mg, 5 mg


zafirlukast oral tablet 10 mg, 20 mg 2 GC

zileuton er oral tablet extended release 12 hour 600 mg


Broncodilatadores, Anticolinérgicos ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT

3

ipratropium bromide inhalation solution 0.02 % 2 PA B/D; GC

ipratropium bromide nasal solution 0.03 %, 0.06 %

2 GC

SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG

3

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT

3

TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT

4

TUDORZA PRESSAIR INHALATION AEROSOL POWDER, BREATH ACTIVATED 400 MCG/ACT (30 ACTUATE)

4

Broncodilatadores, Simpaticomiméticos albuterol sulfate er oral tablet extended release 12 hour 4 mg, 8 mg

2 GC


58


Requisitos/Limites

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml

2 PA B/D; GC

albuterol sulfate oral syrup 2 mg/5ml 2 GC

albuterol sulfate oral tablet 2 mg, 4 mg 2 GC

DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT

3 ST

epinephrine injection solution 0.3 mg/0.3ml 2 GC

epinephrine injection solution auto-injector 0.15 mg/0.3ml, 0.3 mg/0.3ml

2 GC

LEVALBUTEROL TARTRATE INHALATION AEROSOL 45 MCG/ACT

4 ST

metaproterenol sulfate oral syrup 10 mg/5ml 2 GC

metaproterenol sulfate oral tablet 10 mg, 20 mg 2 GC

PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT

4

PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT

4

PROVENTIL HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT

4

SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE

3

terbutaline sulfate injection solution 1 mg/ml 2 GC

terbutaline sulfate oral tablet 2.5 mg, 5 mg 2 GC

VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT

3

Estabilizadores De Mastocitos cromolyn sodium inhalation nebulization solution 20 mg/2ml

2 PA B/D; GC

cromolyn sodium oral concentrate 100 mg/5ml 2 GC

Inhibidores De La Fosfodiesterasa, Enfermedades En Las Vías Respiratorias aminophylline intravenous solution 25 mg/ml 2 GC


59


Requisitos/Limites

DALIRESP ORAL TABLET 250 MCG, 500 MCG


theophylline er oral tablet extended release 12 hour 100 mg, 200 mg, 300 mg

2 GC

theophylline er oral tablet extended release 12 hour 450 mg

2 GC

Agentes Para Enfermedad Inflamatoria Intestinal Aminosalicilatos

APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM


balsalazide disodium oral capsule 750 mg 2 GC

CANASA RECTAL SUPPOSITORY 1000 MG 3

DELZICOL ORAL CAPSULE DELAYED RELEASE 400 MG

4 ST

DIPENTUM ORAL CAPSULE 250 MG 5

mesalamine rectal enema 4 gm 2 GC

PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG, 500 MG


Glucocorticoides COLOCORT RECTAL ENEMA 100 MG/60ML 3

hydrocortisone rectal cream 2.5 % 2 GC

hydrocortisone rectal enema 100 mg/60ml 2 GC

procto-med hc rectal cream 2.5 % 2 GC

PROCTOSOL HC RECTAL CREAM 2.5 % 3

PROCTOZONE-HC RECTAL CREAM 2.5 % 3

Sulfonamidas sulfasalazine oral tablet 500 mg 2 GC

sulfasalazine oral tablet delayed release 500 mg 2 GC

Agentes Para Enfermedades Óseas Metabólicas Agentes Para Enfermedades Óseas Metabólicas

alendronate sodium oral tablet 10 mg, 40 mg, 5 mg

2 GC


60


Requisitos/Limites

alendronate sodium oral tablet 35 mg, 70 mg 1 GC

calcitonin (salmon) nasal solution 200 unit/act 4

calcitriol intravenous solution 1 mcg/ml 2 GC

calcitriol oral capsule 0.25 mcg, 0.5 mcg 2 GC

calcitriol oral solution 1 mcg/ml 2 GC

doxercalciferol intravenous solution 4 mcg/2ml 4

doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg

4

etidronate disodium oral tablet 200 mg, 400 mg 2 GC

FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML


ibandronate sodium oral tablet 150 mg 4 QL (1 EA per 28 days)

MIACALCIN INJECTION SOLUTION 200 UNIT/ML

4

NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, 25 MCG, 50 MCG, 75 MCG

5 PA; LA

PARICALCITOL INTRAVENOUS SOLUTION 2 MCG/ML, 5 MCG/ML

4

paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg 4

PROLIA SUBCUTANEOUS SOLUTION 60 MG/ML

4 PA

risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 35 mg (12 pack), 35 mg (4 pack), 5 mg

4

risedronate sodium oral tablet delayed release 35 mg

4

TYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR 3120 MCG/1.56ML

5 PA

XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7ML

5 PA

zoledronic acid intravenous concentrate 4 mg/5ml 4

zoledronic acid intravenous solution 5 mg/100ml 4

Agentes Para Tratamiento Antiadicción/Abuso De Sustancias Agentes De Cesación De Tabaquismo


61


Requisitos/Limites

bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 mg

2 GC

CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG


CHANTIX ORAL TABLET 0.5 MG, 1 MG 4 QL (360 EA per 365 days)

CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42

4

NICOTROL INHALATION INHALER 10 MG 4

NICOTROL NS NASAL SOLUTION 10 MG/ML 3 QL (720 ML per 365 days)

Agentes De Reversión De Opioides naloxone hcl injection solution prefilled syringe 2 mg/2ml

2 GC

NARCAN NASAL LIQUID 4 MG/0.1ML 3

Ansiolíticos/Disuasivos Del Alcohol acamprosate calcium oral tablet delayed release 333 mg

4

disulfiram oral tablet 250 mg, 500 mg 2 GC

Tratamiento De Dependencia De Opioides buprenorphine hcl injection solution 0.3 mg/ml, 0.3 mg/ml (cartridge)

4

buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg


buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg, 8-2 mg


naltrexone hcl oral tablet 50 mg 2 GC

SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4-1 MG, 8-2 MG


Agentes Terapéuticos Misceláneos Agentes Terapéuticos Misceláneos

curity gauze pad 2"x2" 2 GC

cvs gauze sterile pad 2"x2" 2 GC

global alcohol prep ease pad 70 % 2 GC


62


Requisitos/Limites

Analgésicos Analgésicos

acetaminophen-codeine #2 oral tablet 300-15 mg 2 GC; QL (6 EA per 1 day)



acetaminophen-codeine oral solution 120-12 mg/5ml

2 GC

acetaminophen-codeine oral tablet 300-15 mg, 300-60 mg


butalbital-apap-caffeine oral capsule 50-325-40 mg

4

butalbital-apap-caffeine oral tablet 50-325-40 mg 4

butalbital-aspirin-caffeine oral capsule 50-325-40 mg

4

CAPACET ORAL CAPSULE 50-325-40 MG 4

ENDOCET ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG


esgic oral capsule 50-325-40 mg 4

hydrocodone-acetaminophen oral tablet 5-325 mg, 7.5-325 mg


hydrocodone-ibuprofen oral tablet 7.5-200 mg 2 GC; QL (6 EA per 1 day)

LORCET ORAL TABLET 5-325 MG 3 QL (6 EA per 1 day)

LORCET PLUS ORAL TABLET 7.5-325 MG 3 QL (6 EA per 1 day)

LORTAB ORAL TABLET 5-325 MG, 7.5-325 MG


oxycodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg


zebutal oral capsule 50-325-40 mg 4

Analgésicos Opioides, Acción Corta CODEINE SULFATE ORAL TABLET 15 MG, 30 MG, 60 MG


duramorph injection solution 1 mg/ml 4 QL (120 ML per 1 day)

endocet oral tablet 2.5-325 mg 2 GC; QL (6 EA per 1 day)


63


Requisitos/Limites

fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 400 mcg, 600 mcg, 800 mcg


hydrocodone-acetaminophen oral tablet 10-325 mg


hydromorphone hcl oral tablet 2 mg, 4 mg 2 GC; QL (6 EA per 1 day)

hydromorphone hcl oral tablet 8 mg 2 GC; QL (3 EA per 1 day)

LAZANDA NASAL SOLUTION 100 MCG/ACT, 400 MCG/ACT


LORCET HD ORAL TABLET 10-325 MG 3 QL (6 EA per 1 day)

LORTAB ORAL TABLET 10-325 MG 3 QL (6 EA per 1 day)

morphine sulfate (pf) injection solution 1 mg/ml 4 QL (120 ML per 1 day)

MORPHINE SULFATE INTRAVENOUS SOLUTION 150 MG/30ML

3

nalbuphine hcl injection solution 10 mg/ml, 20 mg/ml

2 GC

oxycodone hcl oral tablet 10 mg, 5 mg 2 GC; QL (6 EA per 1 day)

oxycodone hcl oral tablet 15 mg 2 GC; QL (5 EA per 1 day)



oxycodone-acetaminophen oral tablet 2.5-325 mg 2 GC; QL (6 EA per 1 day)

tramadol hcl oral tablet 50 mg 2 GC; QL (8 EA per 1 day)

Analgésicos Opioides, Efecto Prolongado fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr


LAZANDA NASAL SOLUTION 300 MCG/ACT 5 PA; QL (1 EA per 1 day)

methadone hcl oral tablet 10 mg 2 GC; QL (4 EA per 1 day)

methadone hcl oral tablet 5 mg 2 GC; QL (6 EA per 1 day)

morphine sulfate er oral tablet extended release 100 mg, 200 mg, 60 mg


morphine sulfate er oral tablet extended release 15 mg, 30 mg


morphine sulfate oral solution 20 mg/5ml 2 GC; QL (30 ML per 1 day)

MORPHINE SULFATE ORAL TABLET 15 MG 3 QL (6 EA per 1 day) En la página 8 puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla.

64


Requisitos/Limites

MORPHINE SULFATE ORAL TABLET 30 MG 3 QL (4 EA per 1 day)

oxymorphone hcl er oral tablet extended release 12 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg


tramadol hcl er oral tablet extended release 24 hour 100 mg


tramadol hcl er oral tablet extended release 24 hour 200 mg


Medicamentos Antiinflamatorios No Esteroideos celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg


diclofenac sodium er oral tablet extended release 24 hour 100 mg

2 GC

diclofenac sodium oral tablet delayed release 25 mg, 50 mg

2 GC

diclofenac sodium oral tablet delayed release 75 mg

1 GC

etodolac oral capsule 200 mg, 300 mg 2 GC

etodolac oral tablet 400 mg, 500 mg 2 GC

FENOPROFEN CALCIUM ORAL TABLET 600 MG

3

flurbiprofen oral tablet 100 mg, 50 mg 2 GC

ketoprofen oral capsule 50 mg, 75 mg 2 GC

meloxicam oral tablet 15 mg, 7.5 mg 1 GC

nabumetone oral tablet 500 mg, 750 mg 2 GC

naproxen dr oral tablet delayed release 500 mg 1 GC

naproxen oral suspension 125 mg/5ml 2 GC

naproxen oral tablet 250 mg, 375 mg, 500 mg 1 GC

naproxen sodium oral tablet 275 mg, 550 mg 1 GC

oxaprozin oral tablet 600 mg 2 GC

piroxicam oral capsule 10 mg, 20 mg 2 GC

PROFENO ORAL TABLET 600 MG 3

sulindac oral tablet 150 mg, 200 mg 2 GC


65


Requisitos/Limites

Anestésicos Anestésicos Locales

dermacinrx empricaine external kit 2.5-2.5 % 2 GC

glydo external gel 2 % 2 GC

lidocaine external ointment 5 % 2 GC

lidocaine external patch 5 % 4 PA; QL (3 EA per 1 day)

lidocaine hcl (pf) injection solution 0.5 % 2 GC

lidocaine hcl external gel 2 % 2 GC

lidocaine hcl external solution 4 % 2 GC

lidocaine viscous mouth/throat solution 2 % 2 GC

lidocaine-prilocaine external cream 2.5-2.5 % 2 GC

lidocaine-prilocaine external kit 2.5-2.5 % 2 GC

liprozonepak external kit 2.5-2.5 % 2 GC

regenecare ha external gel 2 % 2 GC

relador pak external kit 2.5-2.5 % 2 GC

Ansiolíticos Ansiolíticos, Otros

buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg

2 GC

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 4 PA

hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg

4 PA

triazolam oral tablet 0.125 mg, 0.25 mg 2 GC; QL (2 EA per 1 day)

Benzodiazepinas alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg 2 GC; QL (3 EA per 1 day)

alprazolam oral tablet 2 mg 2 GC; QL (5 EA per 1 day)

chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg

2 PA; GC; QL (4 EA per 1 day)

clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg



66


Requisitos/Limites

DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML

4

diazepam oral solution 1 mg/ml 4 QL (40 EA per 1 day)

diazepam oral solution 5 mg/5ml 4 QL (40 ML per 1 day)

diazepam oral tablet 2 mg, 5 mg 2 GC; QL (4 EA per 1 day)

lorazepam oral tablet 0.5 mg, 1 mg 2 GC; QL (3 EA per 1 day)

lorazepam oral tablet 2 mg 2 GC; QL (5 EA per 1 day)

Isrs/Irsn (Inhibidores Selectivos De La Recaptación De Serotonina/Inhibidores De La Recaptación De Serotonina Y Norepinefrina)

DULOXETINE HCL ORAL CAPSULE DELAYED RELEASE PARTICLES 40 MG


paroxetine hcl oral tablet 20 mg 2 PA; GC

Antibacteriales Aminoglucósidos

amikacin sulfate injection solution 500 mg/2ml 2 GC

GENTAK OPHTHALMIC OINTMENT 0.3 % 3

GENTAMICIN SULFATE EXTERNAL CREAM 0.1 %

3

GENTAMICIN SULFATE EXTERNAL OINTMENT 0.1 %

3

gentamicin sulfate injection solution 10 mg/ml 2 GC

gentamicin sulfate injection solution 40 mg/ml 2 GC

gentamicin sulfate intravenous solution 10 mg/ml 2 GC

gentamicin sulfate ophthalmic solution 0.3 % 2 GC

neomycin sulfate oral tablet 500 mg 2 GC

paromomycin sulfate oral capsule 250 mg 2 GC

STREPTOMYCIN SULFATE INTRAMUSCULAR SOLUTION RECONSTITUTED 1 GM

3

TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 %

3

tobramycin inhalation nebulization solution 300 mg/5ml

5 PA B/D


67


Requisitos/Limites

tobramycin ophthalmic solution 0.3 % 2 GC

tobramycin sulfate injection solution 10 mg/ml, 80 mg/2ml

2 GC

Antibacteriales colistimethate sodium (cba) injection solution reconstituted 150 mg

2 GC

colistimethate sodium injection solution reconstituted 150 mg

2 GC

SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED 150-350 MG

5

Antibacteriales, Otros alcohol prep pad 70 % 2 GC

BACITRACIN OPHTHALMIC OINTMENT 500 UNIT/GM

3

BACTROBAN NASAL NASAL OINTMENT 2 %

4

CENTANY EXTERNAL OINTMENT 2 % 3

CHLORAMPHENICOL SOD SUCCINATE INTRAVENOUS SOLUTION RECONSTITUTED 1 GM

3

clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg

2 GC

clindamycin phosphate external gel 1 % 2 GC

clindamycin phosphate external solution 1 % 2 GC

clindamycin phosphate in d5w intravenous solution 300 mg/50ml, 600 mg/50ml, 900 mg/50ml

4

clindamycin phosphate vaginal cream 2 % 2 GC

daptomycin intravenous solution reconstituted 500 mg

5

lincomycin hcl injection solution 300 mg/ml 4

linezolid intravenous solution 600 mg/300ml 5

linezolid oral suspension reconstituted 100 mg/5ml 5 PA

linezolid oral tablet 600 mg 5 PA


68


Requisitos/Limites

metronidazole external cream 0.75 % 2 GC

metronidazole external gel 0.75 % 2 GC

metronidazole external lotion 0.75 % 2 GC

metronidazole in nacl intravenous solution 500-0.79 mg/100ml-%

2 GC

metronidazole oral capsule 375 mg 4

metronidazole oral tablet 250 mg, 500 mg 2 GC

metronidazole vaginal gel 0.75 % 2 GC

MONUROL ORAL PACKET 3 GM 4

mupirocin external ointment 2 % 2 GC

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg

2 PA; GC

nitrofurantoin monohyd macro oral capsule 100 mg

2 PA; GC

nitrofurantoin oral suspension 25 mg/5ml 2 PA; GC

rosadan external cream 0.75 % 2 GC

rosadan external gel 0.75 % 2 GC

tigecycline intravenous solution reconstituted 50 mg

4

trimethoprim oral tablet 100 mg 2 GC

vancomycin hcl intravenous solution reconstituted 1000 mg, 500 mg

2 GC

vancomycin hcl intravenous solution reconstituted 750 mg

2 GC

vancomycin hcl oral capsule 125 mg, 250 mg 4

VANDAZOLE VAGINAL GEL 0.75 % 3

XIFAXAN ORAL TABLET 200 MG 4 PA; QL (3 EA per 1 day)

XIFAXAN ORAL TABLET 550 MG 5 PA; QL (3 EA per 1 day)

Betalactamasa, Cefalosporinas AVYCAZ INTRAVENOUS SOLUTION RECONSTITUTED 2.5 (2-0.5) GM

5

CEFACLOR ER ORAL TABLET EXTENDED RELEASE 12 HOUR 500 MG

3


69


Requisitos/Limites

cefaclor oral capsule 250 mg, 500 mg 2 GC

cefadroxil oral capsule 500 mg 2 GC

cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml

2 GC

cefadroxil oral tablet 1 gm 2 GC

cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 500 mg

2 GC

cefdinir oral capsule 300 mg 2 GC

cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

2 GC

cefepime hcl injection solution reconstituted 1 gm, 2 gm

2 GC

cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml

4

cefotaxime sodium injection solution reconstituted 1 gm, 2 gm

2 GC

cefoxitin sodium intravenous solution reconstituted 1 gm, 2 gm

2 GC

cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml

2 GC

cefpodoxime proxetil oral tablet 100 mg, 200 mg 2 GC

cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

2 GC

cefprozil oral tablet 250 mg, 500 mg 2 GC

ceftazidime injection solution reconstituted 2 gm 2 GC

CEFTIN ORAL SUSPENSION RECONSTITUTED 250 MG/5ML

3

ceftriaxone sodium injection solution reconstituted 100 gm

2 GC

ceftriaxone sodium injection solution reconstituted 250 mg, 500 mg

2 GC

ceftriaxone sodium intravenous solution reconstituted 10 gm

2 GC

cefuroxime axetil oral tablet 250 mg, 500 mg 2 GC


70


Requisitos/Limites

cefuroxime sodium injection solution reconstituted 1.5 gm

2 GC

cefuroxime sodium injection solution reconstituted 7.5 gm, 750 mg

2 GC

cefuroxime sodium intravenous solution reconstituted 1.5 gm

2 GC

cephalexin oral capsule 250 mg, 500 mg 2 GC

cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

2 GC

SUPRAX ORAL CAPSULE 400 MG 3

TAZICEF INJECTION SOLUTION RECONSTITUTED 2 GM

3

TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 400 MG, 600 MG

4

Betalactamasa, Otras AZTREONAM INJECTION SOLUTION RECONSTITUTED 1 GM

4

aztreonam injection solution reconstituted 2 gm 4

ertapenem sodium injection solution reconstituted 1 gm

4

imipenem-cilastatin intravenous solution reconstituted 250 mg, 500 mg

2 GC

INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM

4

meropenem intravenous solution reconstituted 1 gm, 500 mg

2 GC

Betalactamasa, Penicilinas amoxicillin oral capsule 250 mg, 500 mg 2 GC

amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml

2 GC

amoxicillin oral tablet 500 mg, 875 mg 2 GC

amoxicillin oral tablet chewable 125 mg, 250 mg 2 GC


71


Requisitos/Limites

amoxicillin-pot clavulanate oral suspension reconstituted 200-28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 mg/5ml

2 GC

amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg

2 GC

amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg, 400-57 mg

2 GC

ampicillin oral capsule 250 mg 2 GC

ampicillin oral capsule 500 mg 2 GC

AMPICILLIN ORAL SUSPENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML

3

ampicillin sodium injection solution reconstituted 1 gm

2 GC

ampicillin sodium injection solution reconstituted 10 gm

2 GC

ampicillin sodium intravenous solution reconstituted 10 gm

2 GC

ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm, 3 (2-1) gm

2 GC

ampicillin-sulbactam sodium intravenous solution reconstituted 15 (10-5) gm, 3 (2-1) gm

2 GC

BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION 900000-300000 UNIT/2ML

3

BICILLIN C-R INTRAMUSCULAR SUSPENSION 1200000 UNIT/2ML

3

dicloxacillin sodium oral capsule 250 mg, 500 mg 2 GC

nafcillin sodium injection solution reconstituted 1 gm, 10 gm

4

nafcillin sodium intravenous solution reconstituted 10 gm

4

NAFCILLIN SODIUM INTRAVENOUS SOLUTION RECONSTITUTED 2 GM

4

penicillin g potassium injection solution reconstituted 20000000 unit, 5000000 unit

4


72


Requisitos/Limites

penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml

2 GC

penicillin v potassium oral tablet 250 mg, 500 mg 2 GC

piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 (2-0.25) gm, 3.375 (3-0.375) gm

4

Macrólidos AZASITE OPHTHALMIC SOLUTION 1 % 4

azithromycin intravenous solution reconstituted 500 mg

2 GC

azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack), 600 mg

2 GC

clarithromycin er oral tablet extended release 24 hour 500 mg

2 GC

clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml

2 GC

clarithromycin oral tablet 250 mg, 500 mg 2 GC

DIFICID ORAL TABLET 200 MG 5 PA; QL (20 EA per 30 days)

ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG

4

ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

3

ERYTHROMYCIN BASE ORAL TABLET 250 MG, 500 MG

3

ERYTHROMYCIN ETHYLSUCCINATE ORAL SUSPENSION RECONSTITUTED 200 MG/5ML

3

erythromycin external solution 2 % 2 GC

erythromycin ophthalmic ointment 5 mg/gm 2 GC

Quinolonas CILOXAN OPHTHALMIC OINTMENT 0.3 % 3

ciprofloxacin hcl ophthalmic solution 0.3 % 2 GC

ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg

2 GC


73


Requisitos/Limites

ciprofloxacin in d5w intravenous solution 200 mg/100ml

2 GC

ciprofloxacin intravenous solution 400 mg/40ml 2 GC

ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), 500 mg/5ml (10%)

2 GC

gatifloxacin ophthalmic solution 0.5 % 4

levofloxacin in d5w intravenous solution 750 mg/150ml

4

levofloxacin intravenous solution 25 mg/ml 4

levofloxacin oral solution 25 mg/ml 2 GC

levofloxacin oral tablet 250 mg, 500 mg, 750 mg 2 GC

moxifloxacin hcl ophthalmic solution 0.5 % 4

ofloxacin ophthalmic solution 0.3 % 2 GC

ofloxacin oral tablet 300 mg, 400 mg 2 GC

ofloxacin otic solution 0.3 % 2 GC

Sulfonamidas silver sulfadiazine external cream 1 % 2 GC

SSD EXTERNAL CREAM 1 % 3

SULFACETAMIDE SODIUM OPHTHALMIC OINTMENT 10 %

4

sulfacetamide sodium ophthalmic solution 10 % 2 GC

SULFADIAZINE ORAL TABLET 500 MG 3

SULFAMETHOXAZOLE-TRIMETHOPRIM INTRAVENOUS SOLUTION 400-80 MG/5ML

3

sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml

2 GC

sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 mg

2 GC

Tetraciclinas doxy 100 intravenous solution reconstituted 100 mg

4

doxycycline hyclate intravenous solution reconstituted 100 mg

4


74


Requisitos/Limites

doxycycline hyclate oral capsule 100 mg, 50 mg 4

doxycycline hyclate oral tablet 100 mg 4

doxycycline hyclate oral tablet 20 mg 2 GC

doxycycline monohydrate oral capsule 100 mg, 50 mg

2 GC

minocycline hcl oral capsule 100 mg, 50 mg, 75 mg

2 GC

minocycline hcl oral tablet 100 mg, 50 mg, 75 mg 2 GC

mondoxyne nl oral capsule 100 mg, 50 mg 2 GC

morgidox oral capsule 100 mg, 50 mg 4

okebo oral capsule 100 mg 2 GC

Anticonvulsivos Agentes De Los Canales De Sodio

APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG

4 ST

BANZEL ORAL SUSPENSION 40 MG/ML 4 ST

BANZEL ORAL TABLET 200 MG, 400 MG 4 ST

carbamazepine er oral tablet extended release 12 hour 100 mg

4

carbamazepine er oral tablet extended release 12 hour 200 mg, 400 mg

2 GC

carbamazepine oral suspension 100 mg/5ml 2 GC

carbamazepine oral tablet 200 mg 2 GC

carbamazepine oral tablet chewable 100 mg 2 GC

DILANTIN ORAL CAPSULE 30 MG 4

EPITOL ORAL TABLET 200 MG 3

fosphenytoin sodium injection solution 100 mg pe/2ml

4

oxcarbazepine oral suspension 300 mg/5ml 2 GC

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg 2 GC

PEGANONE ORAL TABLET 250 MG 4

phenytoin oral suspension 125 mg/5ml 2 GC


75


Requisitos/Limites

phenytoin oral tablet chewable 50 mg 2 GC

phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg

2 GC

phenytoin sodium injection solution 50 mg/ml 2 GC

VIMPAT INTRAVENOUS SOLUTION 200 MG/20ML

4 ST

VIMPAT ORAL SOLUTION 10 MG/ML 4 ST

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG


Agentes Modificadores De Los Canales De Calcio CELONTIN ORAL CAPSULE 300 MG 4

ethosuximide oral capsule 250 mg 2 GC

ethosuximide oral solution 250 mg/5ml 2 GC

LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HOUR 165 MG, 330 MG, 82.5 MG


LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG, 75 MG


LYRICA ORAL CAPSULE 225 MG, 300 MG 3 QL (2 EA per 1 day)

LYRICA ORAL SOLUTION 20 MG/ML 3

zonisamide oral capsule 100 mg, 25 mg, 50 mg 2 GC

Agentes Que Aumentan El Ácido Gama-Aminobutírico (Gaba) clonazepam oral tablet 0.5 mg, 1 mg 2 GC; QL (3 EA per 1 day)

clonazepam oral tablet 2 mg 2 GC

clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 mg


clonazepam oral tablet dispersible 2 mg 4

diazepam oral tablet 10 mg 2 GC; QL (4 EA per 1 day)

divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg

2 GC

divalproex sodium oral capsule delayed release sprinkle 125 mg

2 GC

divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg

2 GC


76


Requisitos/Limites

gabapentin oral capsule 100 mg, 300 mg, 400 mg 2 GC

gabapentin oral solution 250 mg/5ml 2 GC

gabapentin oral tablet 600 mg, 800 mg 2 GC

ONFI ORAL SUSPENSION 2.5 MG/ML 4 ST

ONFI ORAL TABLET 10 MG, 20 MG 4 ST; QL (2 EA per 1 day)

phenobarbital oral elixir 20 mg/5ml 2 GC

phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg

2 GC

primidone oral tablet 250 mg, 50 mg 2 GC

SABRIL ORAL TABLET 500 MG 5

tiagabine hcl oral tablet 12 mg, 16 mg 4

tiagabine hcl oral tablet 2 mg, 4 mg 2 GC

valproate sodium intravenous solution 100 mg/ml 2 GC

valproate sodium oral solution 250 mg/5ml 2 GC

valproic acid oral capsule 250 mg 2 GC

vigabatrin oral packet 500 mg 5

vigadrone oral packet 500 mg 5

Agentes Reductores De Glutamato felbamate oral suspension 600 mg/5ml 2 GC

felbamate oral tablet 400 mg, 600 mg 2 GC

FYCOMPA ORAL SUSPENSION 0.5 MG/ML 4 ST

FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG

4 ST

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg

2 GC

lamotrigine oral tablet chewable 25 mg, 5 mg 2 GC

topiramate oral capsule sprinkle 15 mg, 25 mg 2 GC

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg

2 GC

Anticonvulsivos, Otros BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML

4 ST


77


Requisitos/Limites

BRIVIACT ORAL SOLUTION 10 MG/ML 5 ST; QL (20 ML per 1 day)

BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG


DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG

4

DIASTAT PEDIATRIC RECTAL GEL 2.5 MG 4

levetiracetam in nacl intravenous solution 1000 mg/100ml, 1500 mg/100ml, 500 mg/100ml

2 GC

levetiracetam intravenous solution 500 mg/5ml 2 GC

levetiracetam oral solution 100 mg/ml 2 GC

levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg

2 GC

ROWEEPRA ORAL TABLET 1000 MG, 500 MG, 750 MG

3

SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG, 250 MG, 500 MG


SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 750 MG


Antidepresivos Antidepresivos, Otros

bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg, 150 mg, 200 mg

2 GC

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

2 GC

bupropion hcl oral tablet 100 mg, 75 mg 1 GC

FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG


MAPROTILINE HCL ORAL TABLET 25 MG, 50 MG, 75 MG

3

mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg

2 GC

mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg

2 GC


78


Requisitos/Limites

NEFAZODONE HCL ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG

3

nefazodone hcl oral tablet 250 mg 2 GC

trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg

1 GC

Inhibidores De Monoamino Oxidasa EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR

4

MARPLAN ORAL TABLET 10 MG 4

phenelzine sulfate oral tablet 15 mg 2 GC

tranylcypromine sulfate oral tablet 10 mg 2 GC

Isrs/Irsn (Inhibidores Selectivos De La Recaptación De Serotonina/Inhibidores De La Recaptación De Serotonina Y Norepinefrina)

citalopram hydrobromide oral solution 10 mg/5ml 2 GC

citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg

1 GC

DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 50 MG


desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg, 25 mg, 50 mg


duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg


escitalopram oxalate oral solution 5 mg/5ml 2 GC

escitalopram oxalate oral tablet 10 mg 2 GC; QL (1.5 EA per 1 day)

escitalopram oxalate oral tablet 20 mg, 5 mg 2 GC; QL (1 EA per 1 day)

FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG


fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg 1 GC

fluoxetine hcl oral solution 20 mg/5ml 2 GC

fluoxetine hcl oral tablet 10 mg, 20 mg 2 GC

fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg

2 GC


79


Requisitos/Limites

paroxetine hcl er oral tablet extended release 24 hour 12.5 mg, 25 mg, 37.5 mg

2 PA; GC

paroxetine hcl oral tablet 10 mg, 30 mg, 40 mg 2 PA; GC

PAXIL ORAL SUSPENSION 10 MG/5ML 3 PA

sertraline hcl oral concentrate 20 mg/ml 2 GC

sertraline hcl oral tablet 100 mg, 25 mg, 50 mg 1 GC

TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG


venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg


venlafaxine hcl er oral capsule extended release 24 hour 75 mg


venlafaxine hcl er oral tablet extended release 24 hour 150 mg, 37.5 mg


venlafaxine hcl er oral tablet extended release 24 hour 225 mg


venlafaxine hcl er oral tablet extended release 24 hour 75 mg


venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg

2 GC

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG


VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG

4 ST

Tricíclicos amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

4 PA

AMOXAPINE ORAL TABLET 100 MG, 150 MG, 25 MG, 50 MG

3 PA

clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg

2 PA; GC

desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

2 PA; GC

doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

4 PA


80


Requisitos/Limites

doxepin hcl oral concentrate 10 mg/ml 1 GC

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 4 PA

nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg

1 PA; GC

NORTRIPTYLINE HCL ORAL SOLUTION 10 MG/5ML

3 PA

protriptyline hcl oral tablet 10 mg, 5 mg 2 PA; GC

trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg

4 PA

Antieméticos Antieméticos, Otro

COMPRO RECTAL SUPPOSITORY 25 MG 3

HYDROXYZINE HCL INTRAMUSCULAR SOLUTION 25 MG/ML

4

meclizine hcl oral tablet 25 mg 2 PA; GC

PHENADOZ RECTAL SUPPOSITORY 12.5 MG 3

phenadoz rectal suppository 25 mg 2 GC

PHENERGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG

3

prochlorperazine rectal suppository 25 mg 2 GC

promethazine hcl rectal suppository 12.5 mg, 25 mg

2 GC

promethegan rectal suppository 12.5 mg 2 GC

PROMETHEGAN RECTAL SUPPOSITORY 25 MG

3

scopolamine transdermal patch 72 hour 1 mg/3days


Complementos De La Terapia Emetogénica ALOXI INTRAVENOUS SOLUTION 0.25 MG/5ML

4 PA

aprepitant oral capsule 125 mg, 40 mg 3 PA

aprepitant oral capsule 80 & 125 mg 3 PA; QL (12 EA per 30 days)

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg 4 PA; QL (2 EA per 1 day)


81


Requisitos/Limites

EMEND ORAL SUSPENSION RECONSTITUTED 125 MG

3 PA

granisetron hcl intravenous solution 0.1 mg/ml, 1 mg/ml, 4 mg/4ml

4

granisetron hcl oral tablet 1 mg 2 PA B/D; GC; QL (2 EA per 1 day)

ondansetron hcl injection solution 4 mg/2ml, 4 mg/2ml (2ml syringe)

2 GC

ondansetron hcl oral tablet 4 mg, 8 mg 2 PA B/D; GC

ondansetron oral tablet dispersible 4 mg, 8 mg 2 PA B/D; GC

palonosetron hcl intravenous solution 0.25 mg/2ml, 0.25 mg/5ml

4 PA

Antimicobacteriales Antimicobacteriales, Otros

DAPSONE ORAL TABLET 100 MG, 25 MG 3

PRIFTIN ORAL TABLET 150 MG 3

rifabutin oral capsule 150 mg 4

Antituberculosos CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM

4

ethambutol hcl oral tablet 100 mg, 400 mg 2 GC

ISONIAZID INJECTION SOLUTION 100 MG/ML

3

ISONIAZID ORAL SYRUP 50 MG/5ML 3

isoniazid oral tablet 100 mg, 300 mg 2 GC

PASER ORAL PACKET 4 GM 4

pyrazinamide oral tablet 500 mg 2 GC

rifampin intravenous solution reconstituted 600 mg

2 GC

rifampin oral capsule 150 mg, 300 mg 2 GC

RIFATER ORAL TABLET 50-120-300 MG 4

SIRTURO ORAL TABLET 100 MG 5 PA

TRECATOR ORAL TABLET 250 MG 4


82


Requisitos/Limites

Antimicóticos Antimicóticos

ABELCET INTRAVENOUS SUSPENSION 5 MG/ML

4 PA B/D

AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG

4 PA B/D

AMPHOTERICIN B INJECTION SOLUTION RECONSTITUTED 50 MG

3 PA B/D

caspofungin acetate intravenous solution reconstituted 50 mg

5

caspofungin acetate intravenous solution reconstituted 70 mg

4

ciclodan external cream 0.77 % 2 GC

ciclodan external solution 8 % 2 GC

ciclopirox external gel 0.77 % 2 GC

ciclopirox external shampoo 1 % 2 GC

ciclopirox external solution 8 % 2 GC

ciclopirox olamine external cream 0.77 % 2 GC

ciclopirox olamine external suspension 0.77 % 2 GC

clotrimazole external cream 1 % 2 GC

clotrimazole mouth/throat lozenge 10 mg 2 GC

econazole nitrate external cream 1 % 2 GC

ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG

5

fluconazole in dextrose intravenous solution 200 mg/100ml, 400 mg/200ml

2 GC

fluconazole in sodium chloride intravenous solution 200-0.9 mg/100ml-%, 400-0.9 mg/200ml-%

2 GC

fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml

2 GC

fluconazole oral tablet 100 mg, 200 mg, 50 mg 2 GC

fluconazole oral tablet 150 mg 1 GC


83


Requisitos/Limites

flucytosine oral capsule 250 mg, 500 mg 4

griseofulvin microsize oral suspension 125 mg/5ml 2 GC

itraconazole oral capsule 100 mg 2 GC

ketoconazole external cream 2 % 2 GC

ketoconazole external shampoo 2 % 2 GC

ketoconazole oral tablet 200 mg 2 GC

NATACYN OPHTHALMIC SUSPENSION 5 % 4

NOXAFIL ORAL SUSPENSION 40 MG/ML 5 PA

NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG

5 PA

NYAMYC EXTERNAL POWDER 100000 UNIT/GM

3

NYATA EXTERNAL POWDER 100000 UNIT/GM

3

nystatin external cream 100000 unit/gm 1 GC

nystatin external ointment 100000 unit/gm 1 GC

nystatin external powder 100000 unit/gm 1 GC

nystatin mouth/throat suspension 100000 unit/ml 2 GC

nystatin oral tablet 500000 unit 2 GC

NYSTOP EXTERNAL POWDER 100000 UNIT/GM

3

SPORANOX ORAL SOLUTION 10 MG/ML 4

terbinafine hcl oral tablet 250 mg 2 GC; QL (90 EA per 365 days)

terconazole vaginal cream 0.4 %, 0.8 % 2 GC

terconazole vaginal suppository 80 mg 2 GC

voriconazole intravenous solution reconstituted 200 mg

4 PA

voriconazole oral suspension reconstituted 40 mg/ml

4 PA

voriconazole oral tablet 200 mg 5 PA; QL (2 EA per 1 day)

Antineoplásicos Agentes Alquilantes


84


Requisitos/Limites

busulfan intravenous solution 6 mg/ml 5

cyclophosphamide injection solution reconstituted 1 gm, 2 gm, 500 mg

4

cyclophosphamide oral capsule 25 mg, 50 mg 4 PA B/D

HEXALEN ORAL CAPSULE 50 MG 5 PA

LEUKERAN ORAL TABLET 2 MG 3

MATULANE ORAL CAPSULE 50 MG 5 PA; LA

THIOTEPA INJECTION SOLUTION RECONSTITUTED 15 MG

5 PA

VALCHLOR EXTERNAL GEL 0.016 % 5 PA

YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED 1 MG

5 PA

Agentes Antiangiogénicos POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG

5 PA; LA; QL (21 EA per 28 days)

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG


THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG

5 PA

Antiandrógenos bicalutamide oral tablet 50 mg 2 GC

ERLEADA ORAL TABLET 60 MG 5 PA; QL (4 EA per 1 day)

flutamide oral capsule 125 mg 2 GC

nilutamide oral tablet 150 mg 5

XTANDI ORAL CAPSULE 40 MG 5 PA; LA; QL (4 EA per 1 day)

YONSA ORAL TABLET 125 MG 5 PA; LA; QL (4 EA per 1 day)

ZYTIGA ORAL TABLET 250 MG 5 PA; LA; QL (4 EA per 1 day)

zytiga oral tablet 500 mg 5 PA; LA; QL (2 EA per 1 day)

Anticuerpos Monoclonales ARZERRA INTRAVENOUS CONCENTRATE 100 MG/5ML

5 PA


85


Requisitos/Limites

BAVENCIO INTRAVENOUS SOLUTION 200 MG/10ML

5 PA

BLINCYTO INTRAVENOUS SOLUTION RECONSTITUTED 35 MCG

5 PA

CYRAMZA INTRAVENOUS SOLUTION 100 MG/10ML, 500 MG/50ML

5 PA

DARZALEX INTRAVENOUS SOLUTION 100 MG/5ML

5 PA

EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED 300 MG, 400 MG

5 PA

IMFINZI INTRAVENOUS SOLUTION 120 MG/2.4ML, 500 MG/10ML

5 PA

KEYTRUDA INTRAVENOUS SOLUTION 100 MG/4ML

5 PA

KEYTRUDA INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

5 PA

LARTRUVO INTRAVENOUS SOLUTION 190 MG/19ML

5 PA

OPDIVO INTRAVENOUS SOLUTION 100 MG/10ML, 40 MG/4ML

5 PA

RITUXAN INTRAVENOUS SOLUTION 100 MG/10ML, 500 MG/50ML

5 PA

TECENTRIQ INTRAVENOUS SOLUTION 1200 MG/20ML

5 PA

Antiestrogénicos/Modificadores EMCYT ORAL CAPSULE 140 MG 4 PA

FARESTON ORAL TABLET 60 MG 5 QL (1 EA per 1 day)

SOLTAMOX ORAL SOLUTION 10 MG/5ML 4

tamoxifen citrate oral tablet 10 mg, 20 mg 2 GC

Antimetabolitos adrucil intravenous solution 2.5 gm/50ml, 5 gm/100ml

2 PA B/D; GC

ADRUCIL INTRAVENOUS SOLUTION 500 MG/10ML

3 PA B/D


86


Requisitos/Limites

fluorouracil intravenous solution 1 gm/20ml, 2.5 gm/50ml, 500 mg/10ml

2 PA B/D; GC

fluorouracil intravenous solution 5 gm/100ml 2 PA B/D; GC

hydroxyurea oral capsule 500 mg 2 GC

LONSURF ORAL TABLET 15-6.14 MG 5 PA; QL (100 EA per 28 days)

LONSURF ORAL TABLET 20-8.19 MG 5 PA; QL (80 EA per 28 days)

PURIXAN ORAL SUSPENSION 2000 MG/100ML

5 PA

TABLOID ORAL TABLET 40 MG 4 PA

Antineoplásticos ADCETRIS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG

5 PA

ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 500 MG

5 PA

AVASTIN INTRAVENOUS SOLUTION 100 MG/4ML, 400 MG/16ML

5 PA

azacitidine injection suspension reconstituted 100 mg

5

BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

5 PA

bleomycin sulfate injection solution reconstituted 30 unit

2 PA B/D; GC

bortezomib intravenous solution reconstituted 3.5 mg

5 PA

clofarabine intravenous solution 1 mg/ml 5

dactinomycin intravenous solution reconstituted 0.5 mg

5 PA

decitabine intravenous solution reconstituted 50 mg

5

DOCETAXEL INTRAVENOUS SOLUTION 160 MG/16ML, 80 MG/8ML

4

ELITEK INTRAVENOUS SOLUTION RECONSTITUTED 1.5 MG, 7.5 MG

5

ERBITUX INTRAVENOUS SOLUTION 100 MG/50ML

5


87


Requisitos/Limites

ERWINAZE INJECTION SOLUTION RECONSTITUTED 10000 UNIT

5 PA

FASLODEX INTRAMUSCULAR SOLUTION 250 MG/5ML

5

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG

4

HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 150 MG, 440 MG

5

KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 160 MG

5 PA

LYNPARZA ORAL CAPSULE 50 MG 5 PA; QL (16 EA per 1 day)

LYNPARZA ORAL TABLET 100 MG, 150 MG 5 PA; QL (4 EA per 1 day)

mesna intravenous solution 100 mg/ml 2 GC

MESNEX ORAL TABLET 400 MG 4

mitomycin intravenous solution reconstituted 20 mg, 40 mg

4

MITOMYCIN INTRAVENOUS SOLUTION RECONSTITUTED 5 MG

4

MYLOTARG INTRAVENOUS SOLUTION RECONSTITUTED 4.5 MG

5 PA

NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG


oxaliplatin intravenous solution reconstituted 100 mg

5 PA

paclitaxel intravenous concentrate 100 mg/16.7ml 2 GC

paclitaxel intravenous concentrate 300 mg/50ml 2 GC

PERJETA INTRAVENOUS SOLUTION 420 MG/14ML

5 PA

TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

5

TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 25 MG

5 PA

TRISENOX INTRAVENOUS SOLUTION 12 MG/6ML

5 PA


88


Requisitos/Limites

VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG

5

VENCLEXTA ORAL TABLET 10 MG 4 PA; LA; QL (2 EA per 1 day)



VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 10 & 50 & 100 MG

5 PA; LA; QL (84 EA per 365 days)

VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED 100-44 MG, 44-100 MG

5 PA

ZEJULA ORAL CAPSULE 100 MG 5 PA; LA; QL (3 EA per 1 day)

Antineoplásticos, Otros doxorubicin hcl liposomal intravenous injectable 2 mg/ml

5

epirubicin hcl intravenous solution 200 mg/100ml 2 GC

epirubicin hcl intravenous solution 50 mg/25ml 2 GC

fludarabine phosphate intravenous solution 50 mg/2ml

2 GC

fludarabine phosphate intravenous solution reconstituted 50 mg

2 GC

LARTRUVO INTRAVENOUS SOLUTION 500 MG/50ML

5 PA

leucovorin calcium injection solution reconstituted 100 mg, 350 mg

2 GC

leucovorin calcium injection solution reconstituted 50 mg

2 GC

leucovorin calcium oral tablet 25 mg, 5 mg 2 GC

LIPODOX 50 INTRAVENOUS INJECTABLE 2 MG/ML

5

LIPODOX INTRAVENOUS INJECTABLE 2 MG/ML

5

mitoxantrone hcl intravenous concentrate 25 mg/12.5ml

2 GC

REVLIMID ORAL CAPSULE 2.5 MG, 20 MG 5 PA; LA; QL (1 EA per 1 day)


89


Requisitos/Limites

RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG


SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3.5 MG

5 PA

YERVOY INTRAVENOUS SOLUTION 50 MG/10ML

5 PA

Inhibidores De Aromatasa, 3ª Generación anastrozole oral tablet 1 mg 2 GC

exemestane oral tablet 25 mg 2 GC

letrozole oral tablet 2.5 mg 2 GC

Inhibidores De Dianas Moleculares AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG

5 PA

ALECENSA ORAL CAPSULE 150 MG 5 PA; LA; QL (8 EA per 1 day)

ALUNBRIG ORAL TABLET 180 MG, 90 MG 5 PA; LA; QL (1 EA per 1 day)

ALUNBRIG ORAL TABLET 30 MG 5 PA; LA; QL (6 EA per 1 day)

ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180 MG


BOSULIF ORAL TABLET 100 MG 5 PA; QL (4 EA per 1 day)

BOSULIF ORAL TABLET 400 MG, 500 MG 5 PA; QL (1 EA per 1 day)

CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG


CALQUENCE ORAL CAPSULE 100 MG 5 PA; QL (2 EA per 1 day)

CAPRELSA ORAL TABLET 100 MG, 300 MG 5 PA; LA

COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG

5 PA

COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG

5 PA

COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG

5 PA

COTELLIC ORAL TABLET 20 MG 5 PA; LA; QL (63 EA per 28 days)

ERIVEDGE ORAL CAPSULE 150 MG 5 PA; LA; QL (1 EA per 1 day)


90


Requisitos/Limites

GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG


ICLUSIG ORAL TABLET 15 MG 5 PA; QL (2 EA per 1 day)

ICLUSIG ORAL TABLET 45 MG 5 PA; QL (1 EA per 1 day)

imatinib mesylate oral tablet 100 mg 5 PA; QL (6 EA per 1 day)

imatinib mesylate oral tablet 400 mg 5 PA; QL (2 EA per 1 day)

IMBRUVICA ORAL CAPSULE 140 MG 5 PA; QL (4 EA per 1 day)

IMBRUVICA ORAL CAPSULE 70 MG 5 PA; QL (1 EA per 1 day)

IMBRUVICA ORAL TABLET 140 MG 5 PA; QL (4 EA per 1 day)

IMBRUVICA ORAL TABLET 280 MG, 420 MG, 560 MG


INLYTA ORAL TABLET 1 MG 5 PA; LA; QL (6 EA per 1 day)

INLYTA ORAL TABLET 5 MG 5 PA; LA; QL (4 EA per 1 day)

IRESSA ORAL TABLET 250 MG 5 PA; LA; QL (1 EA per 1 day)

JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG


LENVIMA 10 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 MG


LENVIMA 14 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 & 4 MG


LENVIMA 18 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 & 4 (2) MG


LENVIMA 20 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 (2) MG


LENVIMA 24 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 (2) & 4 MG


LENVIMA 8 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 4 (2) MG


MEKINIST ORAL TABLET 0.5 MG 5 PA; LA; QL (3 EA per 1 day)

MEKINIST ORAL TABLET 2 MG 5 PA; LA; QL (1 EA per 1 day)

NERLYNX ORAL TABLET 40 MG 5 PA; QL (6 EA per 1 day)

NEXAVAR ORAL TABLET 200 MG 5 PA; LA; QL (4 EA per 1 day)

ODOMZO ORAL CAPSULE 200 MG 5 PA; LA; QL (1 EA per 1 day)


91


Requisitos/Limites

RYDAPT ORAL CAPSULE 25 MG 5 PA

SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG


STIVARGA ORAL TABLET 40 MG 5 PA; LA; QL (4 EA per 1 day)

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG


TAFINLAR ORAL CAPSULE 50 MG, 75 MG 5 PA; LA; QL (4 EA per 1 day)

TAGRISSO ORAL TABLET 40 MG, 80 MG 5 PA; LA; QL (1 EA per 1 day)

TARCEVA ORAL TABLET 100 MG, 25 MG 5 PA; LA; QL (2 EA per 1 day)

TARCEVA ORAL TABLET 150 MG 5 PA; LA; QL (3 EA per 1 day)

TASIGNA ORAL CAPSULE 150 MG, 200 MG 5 PA; QL (4 EA per 1 day)

TASIGNA ORAL CAPSULE 50 MG 5 PA; QL (2 EA per 1 day)

TYKERB ORAL TABLET 250 MG 5 PA; LA; QL (6 EA per 1 day)

VOTRIENT ORAL TABLET 200 MG 5 PA; LA; QL (4 EA per 1 day)

XALKORI ORAL CAPSULE 200 MG, 250 MG 5 PA; LA; QL (2 EA per 1 day)

ZELBORAF ORAL TABLET 240 MG 5 PA; LA; QL (8 EA per 1 day)

ZYKADIA ORAL CAPSULE 150 MG 5 PA; LA; QL (5 EA per 1 day)

Inhibidores De La Enzima ALIQOPA INTRAVENOUS SOLUTION RECONSTITUTED 60 MG

5 PA

etoposide intravenous solution 1 gm/50ml, 500 mg/25ml

2 GC

etoposide intravenous solution 100 mg/5ml 2 GC

FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG


IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG


IDHIFA ORAL TABLET 100 MG, 50 MG 5 PA; QL (1 EA per 1 day)

KISQALI 200 DOSE ORAL TABLET 200 MG 5 PA; QL (21 EA per 28 days)




92


Requisitos/Limites

KISQALI FEMARA 200 DOSE ORAL TABLET THERAPY PACK 200 & 2.5 MG






toposar intravenous solution 1 gm/50ml 2 GC

toposar intravenous solution 100 mg/5ml, 500 mg/25ml

2 GC

topotecan hcl intravenous solution reconstituted 4 mg

2 GC

VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG


ZOLINZA ORAL CAPSULE 100 MG 5 PA; QL (4 EA per 1 day)

ZYDELIG ORAL TABLET 100 MG, 150 MG 5 PA; QL (2 EA per 1 day)

Retinoides bexarotene oral capsule 75 mg 5 PA

PANRETIN EXTERNAL GEL 0.1 % 5

TARGRETIN EXTERNAL GEL 1 % 5 PA

tretinoin oral capsule 10 mg 2 GC

Antiparasitarios Antihelmínticos

ALBENZA ORAL TABLET 200 MG 5

BILTRICIDE ORAL TABLET 600 MG 3

ivermectin oral tablet 3 mg 2 GC

Antiprotozoarios ALINIA ORAL TABLET 500 MG 4

atovaquone oral suspension 750 mg/5ml 2 GC

atovaquone-proguanil hcl oral tablet 250-100 mg 4

chloroquine phosphate oral tablet 250 mg, 500 mg 2 GC

COARTEM ORAL TABLET 20-120 MG 4 QL (24 EA per 30 days)

DARAPRIM ORAL TABLET 25 MG 5 PA En la página 8 puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla.

93


Requisitos/Limites

hydroxychloroquine sulfate oral tablet 200 mg 2 GC

mefloquine hcl oral tablet 250 mg 2 GC

NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG

4 PA B/D

PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG

4

PRIMAQUINE PHOSPHATE ORAL TABLET 26.3 MG

3

quinine sulfate oral capsule 324 mg 4 PA; QL (42 EA per 30 days)

Pediculicidas/Escabicidas lindane external shampoo 1 % 2 GC

malathion external lotion 0.5 % 2 GC

permethrin external cream 5 % 2 GC

SKLICE EXTERNAL LOTION 0.5 % 4

Antipsicóticos De Primera Generación/Típicos

CHLORPROMAZINE HCL INJECTION SOLUTION 50 MG/2ML

3

chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg

2 GC

fluphenazine decanoate injection solution 25 mg/ml

2 GC

FLUPHENAZINE HCL INJECTION SOLUTION 2.5 MG/ML

3

FLUPHENAZINE HCL ORAL CONCENTRATE 5 MG/ML

3

FLUPHENAZINE HCL ORAL ELIXIR 2.5 MG/5ML

3

fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg

2 GC

haloperidol decanoate intramuscular solution 100 mg/ml, 100 mg/ml 1 ml, 50 mg/ml

2 GC

haloperidol lactate injection solution 5 mg/ml, 5 mg/ml(1 ml prefilled syringe)

2 GC


94


Requisitos/Limites

haloperidol lactate oral concentrate 2 mg/ml 2 GC

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg

2 GC

loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg

2 GC

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg 2 GC

pimozide oral tablet 1 mg, 2 mg 2 GC

prochlorperazine edisylate injection solution 5 mg/ml

2 GC

prochlorperazine maleate oral tablet 10 mg, 5 mg 2 GC

thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg

2 GC

thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg 2 GC

trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg

2 GC

De Segunda Generación/Atípicos ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 300 MG, 400 MG

5 ST

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED 300 MG, 400 MG

5 ST

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG, 400 MG

5 ST

aripiprazole oral solution 1 mg/ml 4

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg


aripiprazole oral tablet dispersible 10 mg, 15 mg 5 ST; QL (2 EA per 1 day)

ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 MG/3.9ML, 441 MG/1.6ML, 662 MG/2.4ML, 882 MG/3.2ML

5

FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG


GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 20 MG

3


95


Requisitos/Limites

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML

5

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 39 MG/0.25ML, 78 MG/0.5ML

4

INVEGA TRINZA INTRAMUSCULAR SUSPENSION 273 MG/0.875ML, 410 MG/1.315ML, 546 MG/1.75ML, 819 MG/2.625ML

5

LATUDA ORAL TABLET 120 MG 5 ST; QL (1 EA per 1 day)

LATUDA ORAL TABLET 20 MG, 40 MG, 60 MG


LATUDA ORAL TABLET 80 MG 4 ST; QL (2 EA per 1 day)

NUPLAZID ORAL TABLET 17 MG 5 PA; LA; QL (2 EA per 1 day)

olanzapine intramuscular solution reconstituted 10 mg

2 GC

olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg

2 GC

olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg


paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 mg, 9 mg


paliperidone er oral tablet extended release 24 hour 6 mg


quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg

2 GC

REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG


RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG

4

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 37.5 MG, 50 MG

5

risperidone m-tab oral tablet dispersible 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

4


96


Requisitos/Limites

risperidone oral solution 1 mg/ml 2 GC

risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

2 GC

risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

4

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG


VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG


VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 MG


ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg

2 GC

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG

4

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 300 MG, 405 MG

5

Tratamiento-Resistencia clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg

2 GC

CLOZAPINE ORAL TABLET DISPERSIBLE 100 MG, 12.5 MG, 150 MG, 200 MG, 25 MG

4

VERSACLOZ ORAL SUSPENSION 50 MG/ML 4

Antivirales Agentes Anticitomegalovirus (Cmv)

cidofovir intravenous solution 75 mg/ml 5

ganciclovir sodium intravenous solution reconstituted 500 mg

2 PA B/D; GC

valganciclovir hcl oral solution reconstituted 50 mg/ml

5

valganciclovir hcl oral tablet 450 mg 5

ZIRGAN OPHTHALMIC GEL 0.15 % 4

Agentes Antigripales


97


Requisitos/Limites

amantadine hcl oral capsule 100 mg 2 GC

AMANTADINE HCL ORAL TABLET 100 MG 3

oseltamivir phosphate oral capsule 30 mg 4 QL (56 EA per 180 days)

oseltamivir phosphate oral capsule 45 mg, 75 mg 4 QL (28 EA per 180 days)

oseltamivir phosphate oral suspension reconstituted 6 mg/ml


RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER

3

rimantadine hcl oral tablet 100 mg 2 GC

TAMIFLU ORAL CAPSULE 30 MG 4 QL (56 EA per 180 days)

TAMIFLU ORAL CAPSULE 45 MG, 75 MG 4 QL (28 EA per 180 days)

Agentes Antiherpéticos acyclovir external ointment 5 % 4 QL (30 GM per 30 days)

acyclovir oral capsule 200 mg 2 GC

acyclovir oral suspension 200 mg/5ml 2 GC

acyclovir oral tablet 400 mg, 800 mg 2 GC

acyclovir sodium intravenous solution 50 mg/ml 2 PA B/D; GC

DENAVIR EXTERNAL CREAM 1 % 5 QL (5 GM per 90 days)

famciclovir oral tablet 125 mg, 250 mg, 500 mg 2 GC

trifluridine ophthalmic solution 1 % 2 GC

valacyclovir hcl oral tablet 1 gm, 500 mg 4

ZOVIRAX EXTERNAL CREAM 5 % 5 QL (5 GM per 30 days)

Agentes Contra El Vih, Inhibidores De La Integrasa (Insti) BIKTARVY ORAL TABLET 50-200-25 MG 5

GENVOYA ORAL TABLET 150-150-200-10 MG

5

ISENTRESS HD ORAL TABLET 600 MG 5

ISENTRESS ORAL PACKET 100 MG 3

ISENTRESS ORAL TABLET 400 MG 5

ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG

3


98


Requisitos/Limites

STRIBILD ORAL TABLET 150-150-200-300 MG

5

TIVICAY ORAL TABLET 10 MG 4

TIVICAY ORAL TABLET 25 MG, 50 MG 5

Agentes Contra El Vih, Inhibidores No Nucleósidos De La Transcriptasa Inversa (Nnrti, Por Sus Siglas En Inglés)

COMPLERA ORAL TABLET 200-25-300 MG 5

EDURANT ORAL TABLET 25 MG 5

efavirenz oral capsule 200 mg, 50 mg 3

efavirenz oral tablet 600 mg 3

INTELENCE ORAL TABLET 100 MG, 200 MG 5

INTELENCE ORAL TABLET 25 MG 4

nevirapine er oral tablet extended release 24 hour 100 mg, 400 mg

4

NEVIRAPINE ORAL SUSPENSION 50 MG/5ML

4

nevirapine oral tablet 200 mg 2 GC

RESCRIPTOR ORAL TABLET 100 MG, 200 MG

3

SUSTIVA ORAL TABLET 600 MG 3

VIDEX EC ORAL CAPSULE DELAYED RELEASE 125 MG

3

VIRAMUNE ORAL SUSPENSION 50 MG/5ML 4

Agentes Contra El Vih, Inhibidores Nucleósidos Y Nucleóticos De La Transcriptasa Inversa (Nrti, Por Sus Siglas En Inglés)

abacavir sulfate oral solution 20 mg/ml 4

abacavir sulfate oral tablet 300 mg 2 GC

ABACAVIR SULFATE-LAMIVUDINE ORAL TABLET 600-300 MG

5

abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg

5

ATRIPLA ORAL TABLET 600-200-300 MG 5

CIMDUO ORAL TABLET 300-300 MG 5 En la página 8 puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla.

99


Requisitos/Limites

DESCOVY ORAL TABLET 200-25 MG 5

didanosine oral capsule delayed release 125 mg 2 GC

didanosine oral capsule delayed release 200 mg, 250 mg, 400 mg

2 GC

EMTRIVA ORAL CAPSULE 200 MG 4

EMTRIVA ORAL SOLUTION 10 MG/ML 4

JULUCA ORAL TABLET 50-25 MG 5

lamivudine oral solution 10 mg/ml 2 GC

lamivudine oral tablet 100 mg, 150 mg, 300 mg 2 GC

lamivudine-zidovudine oral tablet 150-300 mg 4

ODEFSEY ORAL TABLET 200-25-25 MG 5

RETROVIR INTRAVENOUS SOLUTION 10 MG/ML

4

stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg

2 GC

SYMFI LO ORAL TABLET 400-300-300 MG 5

SYMFI ORAL TABLET 600-300-300 MG 5

tenofovir disoproxil fumarate oral tablet 300 mg 5

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG

5

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM

3

VIREAD ORAL POWDER 40 MG/GM 5

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

5

ZERIT ORAL SOLUTION RECONSTITUTED 1 MG/ML

3

zidovudine oral capsule 100 mg 2 GC

zidovudine oral syrup 50 mg/5ml 2 GC

zidovudine oral tablet 300 mg 2 GC

Agentes Contra El Vih, Otros FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG

5


100


Requisitos/Limites

SELZENTRY ORAL SOLUTION 20 MG/ML 5

SELZENTRY ORAL TABLET 150 MG, 300 MG, 75 MG

5

SELZENTRY ORAL TABLET 25 MG 4

TRIUMEQ ORAL TABLET 600-50-300 MG 5

TYBOST ORAL TABLET 150 MG 3

Agentes Contra La Hepatitis B (Hbv) adefovir dipivoxil oral tablet 10 mg 5

entecavir oral tablet 0.5 mg 4 QL (1 EA per 1 day)

entecavir oral tablet 1 mg 5 QL (1 EA per 1 day)

EPIVIR HBV ORAL SOLUTION 5 MG/ML 3

INTRON A INJECTION SOLUTION 10000000 UNIT/ML, 6000000 UNIT/ML

4

INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT

4

Agentes Contra La Hepatitis C (Hcv) MAVYRET ORAL TABLET 100-40 MG 5 PA; QL (3 EA per 1 day)

MODERIBA ORAL TABLET 200 MG 3

PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 135 MCG/0.5ML, 180 MCG/0.5ML

5

PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML

5

RIBASPHERE ORAL CAPSULE 200 MG 3

RIBASPHERE ORAL TABLET 200 MG 3

ribavirin oral capsule 200 mg 2 GC

ribavirin oral tablet 200 mg 2 GC

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG

5 PA

TECHNIVIE ORAL TABLET 12.5-75-50 MG 5 PA

VIEKIRA PAK ORAL TABLET THERAPY PACK 12.5-75-50 &250 MG



101


Requisitos/Limites

VIEKIRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 200-8.33-50- 33.33 MG


Agentes Contral El Vih, Inhibidores De La Proteasa APTIVUS ORAL CAPSULE 250 MG 5

APTIVUS ORAL SOLUTION 100 MG/ML 5

atazanavir sulfate oral capsule 150 mg, 200 mg, 300 mg

5

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 3

EVOTAZ ORAL TABLET 300-150 MG 5

fosamprenavir calcium oral tablet 700 mg 5

INVIRASE ORAL CAPSULE 200 MG 4

INVIRASE ORAL TABLET 500 MG 5

KALETRA ORAL TABLET 100-25 MG 4

KALETRA ORAL TABLET 200-50 MG 5

LEXIVA ORAL SUSPENSION 50 MG/ML 4

LOPINAVIR-RITONAVIR ORAL SOLUTION 400-100 MG/5ML

5

NORVIR ORAL CAPSULE 100 MG 4

NORVIR ORAL PACKET 100 MG 4

NORVIR ORAL SOLUTION 80 MG/ML 4

PREZCOBIX ORAL TABLET 800-150 MG 5

PREZISTA ORAL SUSPENSION 100 MG/ML 5

PREZISTA ORAL TABLET 150 MG, 75 MG 4

PREZISTA ORAL TABLET 600 MG, 800 MG 5

REYATAZ ORAL PACKET 50 MG 5

ritonavir oral tablet 100 mg 4

VIRACEPT ORAL TABLET 250 MG, 625 MG 5

Nutrientes Terapéuticos/Minerales/Electrolitos Modificadores Electrolito/Mineral

CARBAGLU ORAL TABLET 200 MG 5 PA


102


Requisitos/Limites

CLINISOL SF INTRAVENOUS SOLUTION 15 %

3 PA B/D

EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG

5

FERRIPROX ORAL TABLET 500 MG 5 PA

kcl in d5w lactated ringers intravenous solution 40 meq/l

2 GC

kionex oral suspension 15 gm/60ml 2 GC

KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ

3

KLOR-CON M10 ORAL TABLET EXTENDED RELEASE 10 MEQ

3

KLOR-CON M20 ORAL TABLET EXTENDED RELEASE 20 MEQ

3

klor-con oral packet 20 meq 4

KLOR-CON ORAL TABLET EXTENDED RELEASE 8 MEQ

3

KLOR-CON SPRINKLE ORAL CAPSULE EXTENDED RELEASE 10 MEQ, 8 MEQ

3

K-TAB ORAL TABLET EXTENDED RELEASE 8 MEQ

3

magnesium sulfate injection solution 50 %, 50 % (10ml syringe)

2 GC

PLENAMINE INTRAVENOUS SOLUTION 15 %

3 PA B/D

potassium chloride crys er oral tablet extended release 10 meq, 20 meq

2 GC

potassium chloride er oral capsule extended release 10 meq, 8 meq

2 GC

potassium chloride er oral tablet extended release 10 meq, 20 meq, 8 meq

2 GC

potassium chloride intravenous solution 0.4 meq/ml

2 GC

potassium chloride intravenous solution 10 meq/100ml

2 GC


103


Requisitos/Limites

potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)

4

sodium chloride injection solution 2.5 meq/ml 2 GC

sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 5 %

2 GC

sodium chloride irrigation solution 0.9 % 2 GC

sodium polystyrene sulfonate oral powder 2 GC

sodium polystyrene sulfonate oral suspension 15 gm/60ml

2 GC

sodium polystyrene sulfonate rectal suspension 30 gm/120ml, 50 gm/200ml

2 GC

SPS ORAL SUSPENSION 15 GM/60ML 3

SYPRINE ORAL CAPSULE 250 MG 4

Nutrientes Terapéuticos/Minerales/Electrolitos AMINOSYN II INTRAVENOUS SOLUTION 15 %, 7 %

3 PA B/D

AMINOSYN-HBC INTRAVENOUS SOLUTION 7 %

3 PA B/D

AMINOSYN-PF INTRAVENOUS SOLUTION 7 %

3 PA B/D

CLINIMIX E/DEXTROSE (4.25/25) INTRAVENOUS SOLUTION 4.25 %

4 PA B/D

dextrose in lactated ringers intravenous solution 5 %

2 GC

dextrose intravenous solution 10 %, 5 % 2 GC

DEXTROSE-NACL INTRAVENOUS SOLUTION 10-0.2 %

3

dextrose-nacl intravenous solution 2.5-0.45 %, 5-0.2 %, 5-0.33 %, 5-0.45 %, 5-0.9 %

2 GC

glucose intravenous solution 5 % 2 GC

INTRALIPID INTRAVENOUS EMULSION 20 %

3 PA B/D

kcl in dextrose-nacl intravenous solution 20-5-0.45 meq/l-%-%

2 GC


104


Requisitos/Limites

lactated ringers intravenous solution 2 GC

lactated ringers irrigation solution 2 GC

nutrilipid intravenous emulsion 20 % 2 PA B/D; GC

PRENATAL ORAL TABLET 27-1 MG 3

tpn electrolytes intravenous solution 2 GC

TRIENTINE HCL ORAL CAPSULE 250 MG 4

Productos Para La Sangre/Modificadores/Expansores De Volumen Agentes Modificadores De Las Plaquetas

aspirin-dipyridamole er oral capsule extended release 12 hour 25-200 mg

4

BRILINTA ORAL TABLET 60 MG, 90 MG 3 QL (2 EA per 1 day)

cilostazol oral tablet 100 mg, 50 mg 2 GC

clopidogrel bisulfate oral tablet 75 mg 2 GC

dipyridamole oral tablet 25 mg, 50 mg, 75 mg 2 GC

prasugrel hcl oral tablet 10 mg, 5 mg 4 PA; QL (1 EA per 1 day)

Anticoagulantes COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

3

ELIQUIS ORAL TABLET 2.5 MG, 5 MG 4 PA; QL (2 EA per 1 day)

ELIQUIS STARTER PACK ORAL TABLET 5 MG

4 PA

enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml

2 GC

fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 2.5 mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml

4

FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML

4

heparin (porcine) in d5w intravenous solution 50-5 unit/ml-%

2 GC


105


Requisitos/Limites

heparin (porcine) in nacl injection solution 100-0.45 unit/ml-%, 2-0.9 unit/ml-%, 50-0.45 unit/ml-%

2 GC

heparin sod (porcine) in d5w intravenous solution 100 unit/ml

2 GC

heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml

2 GC

heparin sodium (porcine) solution 20000 unit/ml injection 20000 unit/ml

2 GC

JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

3

PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG


warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

1 GC

XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG

3

XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG

3

Coagulantes tranexamic acid intravenous solution 1000 mg/10ml

2 GC

tranexamic acid oral tablet 650 mg 2 GC

Modificadores Para La Formación De Sangre anagrelide hcl oral capsule 0.5 mg, 1 mg 2 GC

LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 250 MCG

5 PA

MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2ML


NEULASTA ONPRO SUBCUTANEOUS PREFILLED SYRINGE KIT 6 MG/0.6ML

5 PA

NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML

5 PA


106


Requisitos/Limites

NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML

5 PA

NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

5 PA

PROCRIT INJECTION SOLUTION 10000 UNIT/ML

3 PA

PROCRIT INJECTION SOLUTION 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML


PROCRIT INJECTION SOLUTION 20000 UNIT/ML, 40000 UNIT/ML

5 PA

PROMACTA ORAL TABLET 12.5 MG, 25 MG 5 PA; QL (1 EA per 1 day)

PROMACTA ORAL TABLET 50 MG, 75 MG 5 PA; QL (2 EA per 1 day)

RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML


RETACRIT INJECTION SOLUTION 40000 UNIT/ML


ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

5 PA

Reemplazo De Enzimas/Modificadores Reemplazo De Enzimas/Modificadores

ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML

5 LA

ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5ML

5 LA

CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT

5 LA

CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000-76000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT

3

CYSTADANE ORAL POWDER 5

CYSTAGON ORAL CAPSULE 150 MG, 50 MG 3


107


Requisitos/Limites

ELAPRASE INTRAVENOUS SOLUTION 6 MG/3ML

5 LA

FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED 35 MG, 5 MG

5 LA

KUVAN ORAL PACKET 100 MG 5 PA

KUVAN ORAL TABLET SOLUBLE 100 MG 5 PA

miglustat oral capsule 100 mg 5

NAGLAZYME INTRAVENOUS SOLUTION 1 MG/ML

5 LA

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG

5 PA

PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500 UNIT, 16800 UNIT, 21000 UNIT, 4200 UNIT

3

RAVICTI ORAL LIQUID 1.1 GM/ML 5

sodium phenylbutyrate oral tablet 500 mg 5 PA

STRENSIQ SUBCUTANEOUS SOLUTION 40 MG/ML, 80 MG/0.8ML

5 PA

VPRIV INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT

5

Reguladores De Glucosa En La Sangre Agentes Antidiabéticos

acarbose oral tablet 100 mg, 25 mg, 50 mg 2 GC

alogliptin benzoate oral tablet 12.5 mg, 25 mg, 6.25 mg


alogliptin-metformin hcl oral tablet 12.5-1000 mg, 12.5-500 mg


ALOGLIPTIN-PIOGLITAZONE ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG


AVANDIA ORAL TABLET 2 MG, 4 MG 4

BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG/0.85ML



108


Requisitos/Limites

BYDUREON SUBCUTANEOUS PEN-INJECTOR 2 MG


BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER 2 MG


BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 10 MCG/0.04ML

4 ST; QL (2.4 ML per 30 days)

BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 5 MCG/0.02ML

4 ST; QL (1.2 ML per 30 days)

CYCLOSET ORAL TABLET 0.8 MG 4

FARXIGA ORAL TABLET 10 MG, 5 MG 3 ST

glimepiride oral tablet 1 mg, 2 mg 1 GC; QL (3 EA per 1 day)

glimepiride oral tablet 4 mg 1 GC; QL (2 EA per 1 day)

glipizide er oral tablet extended release 24 hour 10 mg


glipizide er oral tablet extended release 24 hour 2.5 mg, 5 mg


glipizide oral tablet 10 mg 1 GC; QL (4 EA per 1 day)

glipizide oral tablet 5 mg 1 GC; QL (3 EA per 1 day)

glipizide xl oral tablet extended release 24 hour 2.5 mg, 5 mg


INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG


INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG, 150-500 MG, 50-1000 MG, 50-500 MG


INVOKANA ORAL TABLET 100 MG, 300 MG 4 ST; QL (1 EA per 1 day)

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG


metformin hcl er oral tablet extended release 24 hour 500 mg


metformin hcl er oral tablet extended release 24 hour 750 mg


metformin hcl oral tablet 1000 mg 1 GC; QL (2.5 EA per 1 day)

metformin hcl oral tablet 500 mg 1 GC; QL (5 EA per 1 day)


109


Requisitos/Limites

metformin hcl oral tablet 850 mg 1 GC; QL (3 EA per 1 day)

nateglinide oral tablet 120 mg, 60 mg 2 GC

pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg 2 GC; QL (1 EA per 1 day)

repaglinide oral tablet 0.5 mg, 1 mg, 2 mg 4

SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2700 MCG/2.7ML

4

SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 1500 MCG/1.5ML

4

TOLBUTAMIDE ORAL TABLET 500 MG 3

TRADJENTA ORAL TABLET 5 MG 4 ST; QL (1 EA per 1 day)

VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML


XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 5-500 MG


XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG


Agentes Glucémicos GLUCAGON EMERGENCY INJECTION KIT 1 MG

3

KORLYM ORAL TABLET 300 MG 5 PA; LA; QL (4 EA per 1 day)

PROGLYCEM ORAL SUSPENSION 50 MG/ML 4

Insulinas assure id insulin safety syr 29g x 1/2" 1 ml 2 GC

comfort assist insulin syringe 29g x 1/2" 1 ml 2 GC

exel comfort point pen needle 29g x 12mm 2 GC; QL (200 EA per 30 days)

FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML


FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML


HUMALOG JUNIOR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML



110


Requisitos/Limites

HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML


HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML


HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML


HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML


HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML


HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML


HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML


HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML


HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML


HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML


HUMULIN R INJECTION SOLUTION 100 UNIT/ML


HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML

4

LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML


LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML


LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML


LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML


novofine 30g x 8 mm , 32g x 6 mm 2 GC


111


Requisitos/Limites

novofine plus 32g x 4 mm 2 GC

NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML


NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML


NOVOLIN N RELION SUBCUTANEOUS SUSPENSION 100 UNIT/ML


NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML


NOVOLIN R INJECTION SOLUTION 100 UNIT/ML


NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML


NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML


NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML


NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML


NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML


NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML


novotwist 32g x 5 mm 2 GC

preferred plus insulin syringe 28g x 1/2" 0.5 ml 2 GC

reli-on insulin syringe 29g 0.3 ml 2 GC

Reguladores De Glucosa En La Sangre glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-500 mg


JANUMET ORAL TABLET 50-1000 MG, 50-500 MG


JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG



112


Requisitos/Limites

JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 50-1000 MG, 50-500 MG


pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg


pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg


repaglinide-metformin hcl oral tablet 1-500 mg, 2-500 mg


Relajantes Musculoesqueléticos Relajantes Musculoesqueléticos

chlorzoxazone oral tablet 500 mg 2 GC

cyclobenzaprine hcl oral tablet 10 mg, 5 mg, 7.5 mg

2 PA; GC; QL (3 EA per 1 day)

orphenadrine citrate er oral tablet extended release 12 hour 100 mg



113

Índice

A abacavir sulfate ................... 99 ABACAVIR SULFATE-

LAMIVUDINE ................... 99 abacavir-lamivudine-

zidovudine ....................... 99 ABELCET .............................. 83 ABILIFY MAINTENA.............. 95 acamprosate calcium .......... 62 acarbose ............................ 108 acebutolol hcl ...................... 12 acetaminophen-codeine ..... 63 acetaminophen-codeine #2 63 acetaminophen-codeine #3 63 acetaminophen-codeine #4 63 ACETASOL HC ...................... 52 acetazolamide ..................... 19 acetylcysteine ..................... 55 acitretin ............................... 22 ACTEMRA ............................ 44 ACTHIB ................................ 47 ACTIMMUNE ....................... 44 acyclovir .............................. 98 acyclovir sodium ................. 98 ADACEL ................................ 47 ADAGEN ............................ 107 ADCETRIS ............................. 87 ADCIRCA .............................. 56 adefovir dipivoxil ............... 101 ADEMPAS ............................ 56 adrucil ................................. 86 ADRUCIL .............................. 86 ADVAIR DISKUS ................... 57 ADVAIR HFA ........................ 57 AFEDITAB CR ....................... 13 AFINITOR ............................. 90 AFINITOR DISPERZ ............... 44 ala-cort ................................ 28 ALBENZA .............................. 93 albuterol sulfate .................. 59 albuterol sulfate er.............. 58 alclometasone dipropionate

........................................ 28 alcohol prep ........................ 68 ALDACTAZIDE ...................... 14 ALDURAZYME .................... 107 ALECENSA ............................ 90

alendronate sodium ...... 60, 61 alfuzosin hcl er .................... 27 ALIMTA ............................... 87 ALINIA ................................. 93 ALIQOPA ............................. 92 allopurinol .............................9 almotriptan malate ............. 10 ALOCRIL .............................. 49 alogliptin benzoate ........... 108 alogliptin-metformin hcl ... 108 ALOGLIPTIN-PIOGLITAZONE

...................................... 108 ALOMIDE ............................ 49 ALORA ................................. 32 alosetron hcl ....................... 24 ALOXI .................................. 81 ALPHAGAN P ....................... 50 alprazolam .......................... 66 ALREX .................................. 51 ALTAVERA ........................... 32 ALUNBRIG ........................... 90 ALYACEN 1/35 .................... 32 ALYACEN 7/7/7 ................... 32 AMABELZ ............................ 32 amantadine hcl ................... 98 AMANTADINE HCL .............. 98 AMBISOME ......................... 83 AMCINONIDE ...................... 28 AMETHIA LO ....................... 32 amikacin sulfate.................. 67 amiloride hcl ....................... 19 amiloride-hydrochlorothiazide

........................................ 14 aminophylline ..................... 59 AMINOSYN II ..................... 104 AMINOSYN-HBC ................ 104 AMINOSYN-PF .................. 104 amiodarone hcl ................... 16 AMITIZA .............................. 25 amitriptyline hcl ................. 80 amlactin .............................. 22 amlodipine besy-benazepril

hcl ................................... 14 amlodipine besylate ........... 13 ammonium lactate ............. 22 AMOXAPINE ........................ 80 amoxicillin ........................... 71

amoxicillin-pot clavulanate . 72 amphetamine-dextroamphet

er ..................................... 54 amphetamine-

dextroamphetamine ....... 54 AMPHOTERICIN B ................ 83 ampicillin ............................. 72 AMPICILLIN ......................... 72 ampicillin sodium ................ 72 ampicillin-sulbactam sodium

........................................ 72 AMPYRA .............................. 52 ANADROL-50 ....................... 32 anagrelide hcl .................... 106 anastrozole ......................... 90 ANDRODERM ...................... 31 ANDROGEL .......................... 32 ANDROGEL PUMP ............... 32 ANDROXY ............................ 32 APOKYN ............................... 11 apraclonidine hcl ................. 50 aprepitant ........................... 81 APRI ..................................... 32 APRISO ................................ 60 APTIOM ............................... 75 APTIVUS ............................ 102 ARANELLE ............................ 32 ARCALYST ............................ 44 aripiprazole ......................... 95 ARISTADA ............................ 95 ARMODAFINIL ..................... 22 ARMOUR THYROID.............. 40 ARZERRA ............................. 85 ASMANEX 120 METERED

DOSES .............................. 57 ASMANEX 30 METERED

DOSES .............................. 57 ASMANEX 60 METERED

DOSES .............................. 57 ASMANEX HFA .................... 57 aspirin-dipyridamole er..... 105 assure id insulin safety syr 110 atazanavir sulfate .............. 102 atenolol ............................... 12 atenolol-chlorthalidone ...... 14 atomoxetine hcl .................. 53 atorvastatin calcium ........... 17

114

atovaquone ......................... 93 atovaquone-proguanil hcl ... 93 ATRIPLA ............................... 99 atropine sulfate ................... 51 ATROVENT HFA ................... 58 AUBAGIO ............................. 52 AUBRA ................................. 32 aubra eq .............................. 32 AUSTEDO ............................. 54 AVANDIA ........................... 108 AVASTIN .............................. 87 AVIANE ................................ 32 avita ..................................... 22 AVONEX ............................... 52 AVONEX PEN ....................... 52 AVONEX PREFILLED ............. 52 AVYCAZ ................................ 69 azacitidine ........................... 87 AZASITE ............................... 73 azathioprine ........................ 44 azelastine hcl ................. 49, 56 AZELEX ................................. 22 azithromycin ....................... 73 AZOPT .................................. 50 aztreonam ........................... 71 AZTREONAM ....................... 71 azurette ............................... 33 B BACITRACIN ......................... 68 bacitracin-polymyxin b ........ 51 bacitra-neomycin-polymyxin-

hc ..................................... 49 baclofen ................................ 9 BACTROBAN NASAL ............ 68 balsalazide disodium ........... 60 BALZIVA ............................... 39 BANZEL ................................ 75 BAVENCIO ........................... 86 BCG VACCINE ...................... 47 BEKYREE .............................. 33 BELEODAQ ........................... 87 BELSOMRA .......................... 22 benazepril hcl ...................... 19 benazepril-

hydrochlorothiazide ........ 14 BENLYSTA ............................ 44 benzoyl peroxide-

erythromycin ................... 22 benztropine mesylate ......... 11 BERINERT............................. 43

betamethasone dipropionate ..................................... 9, 28

betamethasone dipropionate aug .................................. 28

betamethasone valerate .... 28 betaxolol hcl .................. 12, 50 bethanechol chloride.......... 27 BETOPTIC-S ......................... 50 bexarotene ......................... 93 BEXSERO ............................. 47 bicalutamide ....................... 85 BICILLIN C-R ........................ 72 BICILLIN C-R 900/300 .......... 72 BIKTARVY ............................ 98 BILTRICIDE .......................... 93 bisoprolol fumarate ............ 12 bisoprolol-

hydrochlorothiazide ....... 14 bleomycin sulfate ............... 87 BLEPHAMIDE ...................... 49 BLEPHAMIDE S.O.P. ............ 49 BLINCYTO ............................ 86 BLISOVI FE 1.5/30 ............... 33 BLISOVI FE 1/20 .................. 33 BOOSTRIX ........................... 47 bortezomib ......................... 87 BOSULIF .............................. 90 BRIELLYN ............................. 39 BRILINTA ........................... 105 brimonidine tartrate ........... 50 BRIVIACT ........................ 77, 78 bromocriptine mesylate ..... 11 budesonide .................... 25, 57 budesonide er ..................... 25 bumetanide ........................ 18 buprenorphine hcl .............. 62 buprenorphine hcl-naloxone

hcl ................................... 62 bupropion hcl ..................... 78 bupropion hcl er (smoking

det) ................................. 62 bupropion hcl er (sr) ........... 78 bupropion hcl er (xl) ........... 78 buspirone hcl ...................... 66 busulfan .............................. 85 butalbital-apap-caffeine ..... 63 butalbital-aspirin-caffeine .. 63 BYDUREON ....................... 109 BYDUREON BCISE ............. 108 BYETTA 10 MCG PEN ........ 109

BYETTA 5 MCG PEN ........... 109 BYSTOLIC ............................. 12 C cabergoline ......................... 42 CABOMETYX ........................ 90 calcipotriene ................. 22, 23 calcitonin (salmon) .............. 61 calcitriol............................... 61 calcium acetate (phos binder)

........................................ 27 CALQUENCE ........................ 90 CAMILA ............................... 39 CAMRESE LO ....................... 33 CANASA ............................... 60 candesartan cilexetil ........... 16 candesartan cilexetil-hctz ... 14 CAPACET ............................. 63 CAPASTAT SULFATE ............ 82 CAPRELSA ............................ 90 captopril .............................. 19 captopril-hydrochlorothiazide

........................................ 14 CARAFATE ........................... 26 CARBAGLU ........................ 102 carbamazepine .................... 75 carbamazepine er ......... 20, 75 carbidopa-levodopa ............ 12 carbidopa-levodopa er ........ 11 carbidopa-levodopa-

entacapone ..................... 11 carteolol hcl ........................ 50 CARTIA XT ............................ 13 carvedilol ............................. 12 caspofungin acetate ............ 83 CAYSTON ............................. 55 CAZIANT .............................. 33 cefaclor ............................... 70 CEFACLOR ER ...................... 69 cefadroxil ............................ 70 cefazolin sodium ................. 70 cefdinir ................................ 70 cefepime hcl ........................ 70 cefixime ............................... 70 cefotaxime sodium ............. 70 cefoxitin sodium ................. 70 cefpodoxime proxetil .......... 70 cefprozil .............................. 70 ceftazidime.......................... 70 CEFTIN ................................. 70 ceftriaxone sodium ............. 70

115

cefuroxime axetil ................ 70 cefuroxime sodium ............. 71 celecoxib ............................. 65 CELONTIN ............................ 76 CENTANY ............................. 68 cephalexin ........................... 71 CEREZYME ......................... 107 cetirizine hcl ........................ 56 cevimeline hcl ..................... 22 CHANTIX .............................. 62 CHANTIX CONTINUING

MONTH PAK .................... 62 CHANTIX STARTING MONTH

PAK .................................. 62 CHATEAL .............................. 33 chateal eq ............................ 33 CHLORAMPHENICOL SOD

SUCCINATE ...................... 68 chlordiazepoxide hcl ........... 66 chlorhexidine gluconate ...... 22 chloroquine phosphate ....... 93 chlorothiazide ..................... 19 chlorpromazine hcl ............. 94 CHLORPROMAZINE HCL ...... 94 chlorthalidone ..................... 19 chlorzoxazone ................... 113 cholestyramine ................... 18 cholestyramine light ........... 17 ciclodan ............................... 83 ciclopirox ............................. 83 ciclopirox olamine ............... 83 cidofovir .............................. 97 cilostazol ........................... 105 CILOXAN .............................. 73 CIMDUO .............................. 99 cimetidine ........................... 25 CINRYZE ............................... 43 ciprofloxacin ........................ 74 ciprofloxacin hcl .................. 73 ciprofloxacin in d5w ............ 74 citalopram hydrobromide ... 79 claravis ................................ 23 CLARAVIS ............................. 23 clarithromycin ..................... 73 clarithromycin er ................. 73 clindamycin hcl .................... 68 clindamycin phos-benzoyl

perox ............................... 23 clindamycin phosphate ....... 68 clindamycin phosphate in d5w

........................................ 68 CLINIMIX E/DEXTROSE

(4.25/25) ....................... 104 CLINISOL SF ....................... 103 clobetasol propionate ... 23, 28 clobetasol propionate e ..... 28 clofarabine .......................... 87 clomipramine hcl ................ 80 clonazepam ........................ 76 clonidine hcl ....................... 16 clopidogrel bisulfate ......... 105 clorazepate dipotassium .... 66 clotrimazole ........................ 83 clotrimazole-betamethasone

........................................ 23 clozapine ............................. 97 CLOZAPINE .......................... 97 COARTEM ........................... 93 CODEINE SULFATE .............. 63 COLCHICINE ...........................9 colchicine-probenecid ...........9 colestipol hcl ....................... 18 colistimethate sodium ........ 68 colistimethate sodium (cba) 68 COLOCORT .......................... 60 COLY-MYCIN S .................... 52 COMBIGAN ......................... 50 COMBIPATCH ...................... 33 COMBIVENT RESPIMAT ...... 55 COMETRIQ (100 MG DAILY

DOSE) .............................. 90 COMETRIQ (140 MG DAILY

DOSE) .............................. 90 COMETRIQ (60 MG DAILY

DOSE) .............................. 90 comfort assist insulin syringe

...................................... 110 COMPLERA .......................... 99 COMPRO ............................. 81 constulose .......................... 26 CORLANOR .......................... 15 CORMAX SCALP APPLICATION

........................................ 23 CORTISONE ACETATE .......... 29 COTELLIC ............................. 90 COUMADIN ....................... 105 CREON .............................. 107 CRIXIVAN .......................... 102 cromolyn sodium ........... 49, 59 CRYSELLE-28 ....................... 33

CUPRIMINE ......................... 27 curity gauze ......................... 62 cvs gauze sterile .................. 62 CYCLAFEM 1/35 .................. 33 CYCLAFEM 7/7/7 ................. 33 cyclobenzaprine hcl .......... 113 cyclophosphamide .............. 85 CYCLOSET .......................... 109 cyclosporine ........................ 44 cyclosporine modified ......... 44 cyproheptadine hcl ............. 56 CYRAMZA ............................ 86 CYRED .................................. 33 CYSTADANE ....................... 107 CYSTAGON ........................ 107 CYSTARAN ........................... 51 D dactinomycin ...................... 87 dalfampridine er ................. 52 DALIRESP ............................. 60 danazol ................................ 32 DAPSONE ............................ 82 DAPTACEL ........................... 47 daptomycin ......................... 68 DARAPRIM .......................... 93 DARZALEX............................ 86 DASETTA 1/35 ..................... 33 DASETTA 7/7/7.................... 33 DEBLITANE .......................... 39 decitabine ........................... 87 deltasone ............................ 29 DELYLA ................................ 33 DELZICOL ............................. 60 DEMSER ............................... 14 DENAVIR .............................. 98 dermacinrx empricaine ....... 66 DESCOVY ........................... 100 desipramine hcl ................... 80 desmopressin ace rhinal tube

........................................ 40 desmopressin ace spray refrig

........................................ 40 desmopressin acetate ......... 40 desogestrel-ethinyl estradiol

.................................. 31, 33 desoximetasone .................. 29 DESVENLAFAXINE ER ........... 79 desvenlafaxine succinate er 79 dexamethasone .............. 9, 29 DEXAMETHASONE .............. 29

116

DEXAMETHASONE INTENSOL ........................................ 29

dexamethasone sod phosphate pf ................... 29

dexamethasone sodium phosphate ....................... 29

dexedrine ............................ 54 DEXILANT ............................ 25 dexmethylphenidate hcl ..... 53 dexmethylphenidate hcl er . 53 dextroamphetamine sulfate 54 dextroamphetamine sulfate er

........................................ 54 dextrose ............................ 104 dextrose in lactated ringers

...................................... 104 dextrose-nacl .................... 104 DEXTROSE-NACL ................ 104 DIASTAT ACUDIAL ............... 78 DIASTAT PEDIATRIC ............. 78 diazepam ....................... 67, 76 DIAZEPAM INTENSOL .......... 67 diclofenac potassium ............ 9 diclofenac sodium ... 23, 51, 65 diclofenac sodium er ........... 65 dicloxacillin sodium ............. 72 dicyclomine hcl ................... 25 didanosine ......................... 100 DIFICID ................................. 73 DIGITEK................................ 15 digox .................................... 15 digoxin ................................. 15 dihydroergotamine mesylate

........................................ 10 DIHYDROERGOTAMINE

MESYLATE ....................... 10 DILANTIN ............................. 75 diltiazem cd ......................... 13 diltiazem hcl ........................ 13 diltiazem hcl er .................... 13 diltiazem hcl er beads ......... 13 diltiazem hcl er coated beads

........................................ 13 dilt-xr ................................... 13 DIPENTUM .......................... 60 diphenhydramine hcl .......... 56 diphenoxylate-atropine ...... 24 DIPHENOXYLATE-ATROPINE 24 DIPHTHERIA-TETANUS

TOXOIDS DT ..................... 47

dipyridamole .................... 105 disulfiram ............................ 62 divalproex sodium .............. 76 divalproex sodium er .......... 76 DOCETAXEL ......................... 87 DOFETILIDE ......................... 16 donepezil hcl....................... 21 dorzolamide hcl .................. 50 dorzolamide hcl-timolol mal50 doxazosin mesylate ....... 12, 27 doxepin hcl .............. 23, 80, 81 doxercalciferol ............... 41, 61 doxorubicin hcl liposomal .. 89 doxy 100 ............................. 74 doxycycline hyclate ....... 74, 75 doxycycline monohydrate .. 75 dronabinol .......................... 81 DROSPIREN-ETH ESTRAD-

LEVOMEFOL .................... 33 DROSPIRENONE-ETHINYL

ESTRADIOL ...................... 33 DULERA ............................... 59 duloxetine hcl ..................... 79 DULOXETINE HCL ................ 67 duramorph.......................... 63 DUREZOL ............................. 51 dutasteride ......................... 27 DYRENIUM .......................... 19 E econazole nitrate ................ 83 EDURANT ............................ 99 efavirenz ............................. 99 ELAPRASE .......................... 108 ELIGARD .............................. 42 ELINEST ............................... 33 ELIQUIS ............................. 105 ELIQUIS STARTER PACK..... 105 ELITEK ................................. 87 ELLA .................................... 39 ELMIRON ............................ 27 EMADINE ............................ 49 EMCYT................................. 86 EMEND ................................ 82 EMOQUETTE ....................... 34 EMPLICITI ............................ 86 EMSAM ............................... 79 EMTRIVA ........................... 100 enalapril maleate ................ 19 enalapril-hydrochlorothiazide

........................................ 14

ENBREL .......................... 44, 45 ENBREL MINI ....................... 44 ENBREL SURECLICK ............. 45 endocet ............................... 63 ENDOCET ............................. 63 ENGERIX-B ........................... 47 enoxaparin sodium ........... 105 ENPRESSE-28 ....................... 34 ENSKYCE .............................. 34 entacapone ......................... 11 entecavir ........................... 101 ENTRESTO ........................... 16 enulose ................................ 26 epinastine hcl ...................... 49 epinephrine ......................... 59 epirubicin hcl....................... 89 EPITOL ................................. 75 EPIVIR HBV ........................ 101 eplerenone .......................... 19 ERAXIS ................................. 83 ERBITUX .............................. 87 ergoloid mesylates .............. 21 ergotamine-caffeine ........... 10 ERIVEDGE ............................ 90 ERLEADA.............................. 85 ERRIN .................................. 39 ertapenem sodium ............. 71 ERWINAZE ........................... 88 ERY-TAB ............................... 73 ERYTHROCIN LACTOBIONATE

........................................ 73 erythromycin....................... 73 ERYTHROMYCIN BASE ......... 73 ERYTHROMYCIN

ETHYLSUCCINATE ............ 73 ESBRIET ............................... 55 escitalopram oxalate ........... 79 esgic .................................... 63 ESTARYLLA........................... 34 estradiol .............................. 34 estradiol-norethindrone acet

........................................ 34 ESTRING .............................. 34 estropipate .......................... 34 ESTROPIPATE ...................... 34 eszopiclone ......................... 21 ethacrynate sodium ............ 18 ethacrynic acid .................... 18 ethambutol hcl .................... 82 ethosuximide ...................... 76

117

ethynodiol diac-eth estradiol ........................................ 31

etidronate disodium ........... 61 etodolac .............................. 65 etoposide ............................ 92 EVAMIST .............................. 34 EVOTAZ ............................. 102 exel comfort point pen needle

...................................... 110 exemestane ......................... 90 EXJADE .............................. 103 EXTAVIA ............................... 52 ezetimibe ............................ 18 ezetimibe-simvastatin ......... 14 F FABRAZYME ...................... 108 FALMINA ............................. 34 famciclovir ........................... 98 famotidine ........................... 25 FANAPT ............................... 95 FARESTON ........................... 86 FARXIGA ............................ 109 FARYDAK ............................. 92 FASLODEX ............................ 88 felbamate ............................ 77 felodipine er ........................ 13 FEMRING ............................. 34 FEMYNOR ............................ 34 fenofibrate .......................... 17 fenofibrate micronized ....... 17 FENOPROFEN CALCIUM ...... 65 fentanyl ............................... 64 fentanyl citrate .................... 64 FERRIPROX ........................ 103 FETZIMA .............................. 79 FIASP ................................. 110 FIASP FLEXTOUCH ............. 110 FINACEA .............................. 23 finasteride ........................... 27 FIRAZYR ............................... 43 FIRMAGON .......................... 42 flavoxate hcl ........................ 27 flecainide acetate ................ 16 FLOVENT DISKUS ................. 57 FLOVENT HFA ...................... 57 fluconazole .......................... 83 fluconazole in dextrose ....... 83 fluconazole in sodium chloride

........................................ 83 flucytosine ........................... 84

fludarabine phosphate ....... 89 fludrocortisone acetate ...... 29 flunisolide ........................... 57 fluocinolone acetonide ....... 29 fluocinolone acetonide body

........................................ 29 fluocinolone acetonide scalp

........................................ 29 fluocinonide ........................ 29 fluocinonide emulsified base

........................................ 29 fluocinonide-e .................... 29 fluorometholone ................ 51 fluorouracil .................... 23, 87 FLUOROURACIL................... 23 fluoxetine hcl ...................... 79 fluphenazine decanoate ..... 94 fluphenazine hcl ................. 94 FLUPHENAZINE HCL ............ 94 flurazepam hcl .................... 21 flurbiprofen ........................ 65 flurbiprofen sodium............ 51 flutamide ............................ 85 fluticasone propionate .29, 30,

57 FLUTICASONE-SALMETEROL 57 fluvoxamine maleate .......... 79 FML ..................................... 51 FML FORTE.......................... 51 fondaparinux sodium ....... 105 FORFIVO XL ......................... 78 FORTEO ............................... 61 fosamprenavir calcium ..... 102 fosinopril sodium ................ 19 fosinopril sodium-hctz ........ 14 fosphenytoin sodium .......... 75 FRAGMIN .......................... 105 frovatriptan succinate ........ 10 furosemide .................... 18, 19 FUROSEMIDE ...................... 18 FUZEON ............................ 100 fyavolv ................................ 34 FYCOMPA ............................ 77 G gabapentin .......................... 77 galantamine hydrobromide 21 galantamine hydrobromide er

........................................ 21 GAMASTAN S/D .................. 43 GAMUNEX-C ....................... 43

ganciclovir sodium .............. 97 GARDASIL 9 ......................... 47 gatifloxacin .......................... 74 GATTEX ................................ 24 GAVILYTE-C ......................... 26 GAVILYTE-G ......................... 26 GAVILYTE-N WITH FLAVOR

PACK ................................ 26 gemfibrozil .......................... 17 generlac .............................. 26 GENGRAF ............................ 45 GENTAK ............................... 67 gentamicin sulfate .............. 67 GENTAMICIN SULFATE ........ 67 GENVOYA ............................ 98 GEODON.............................. 95 GIANVI ................................. 34 GILDAGIA............................. 39 GILDESS FE 1.5/30 ............... 34 GILDESS FE 1/20 .................. 34 GILOTRIF.............................. 91 glatiramer acetate .............. 52 glatopa ................................ 52 GLEOSTINE .......................... 88 glimepiride ........................ 109 glipizide ............................. 109 glipizide er ......................... 109 glipizide xl ......................... 109 glipizide-metformin hcl ..... 112 global alcohol prep ease ..... 62 GLUCAGON EMERGENCY .. 110 glucose .............................. 104 glycopyrrolate ..................... 25 glydo.................................... 66 GOLYTELY ............................ 26 granisetron hcl .................... 82 griseofulvin microsize ......... 84 guanfacine hcl ..................... 16 guanfacine hcl er ................. 53 guanidine hcl ......................... 9 H halobetasol propionate ...... 30 haloperidol .......................... 95 haloperidol decanoate ........ 94 haloperidol lactate ........ 94, 95 HAVRIX ................................ 47 HEATHER ............................. 39 heparin (porcine) in d5w .. 105 heparin (porcine) in nacl ... 106 heparin sod (porcine) in d5w

118

...................................... 106 heparin sodium (porcine).. 106 HERCEPTIN .......................... 88 HETLIOZ ............................... 22 HEXALEN ............................. 85 HIBERIX ................................ 47 HIZENTRA ............................ 43 HUMALOG ......................... 111 HUMALOG JUNIOR KWIKPEN

...................................... 110 HUMALOG KWIKPEN ......... 111 HUMALOG MIX 50/50 ....... 111 HUMALOG MIX 50/50

KWIKPEN ....................... 111 HUMALOG MIX 75/25 ....... 111 HUMALOG MIX 75/25

KWIKPEN ....................... 111 HUMIRA............................... 45 HUMIRA PEDIATRIC CROHNS

START .............................. 45 HUMIRA PEN ....................... 45 HUMIRA PEN-CD/UC/HS

STARTER .......................... 45 HUMIRA PEN-PS/UV STARTER

........................................ 45 HUMULIN 70/30 ................ 111 HUMULIN 70/30 KWIKPEN 111 HUMULIN N ....................... 111 HUMULIN N KWIKPEN....... 111 HUMULIN R ....................... 111 HUMULIN R U-500

(CONCENTRATED) ......... 111 hydralazine hcl .................... 20 hydrochlorothiazide ............ 19 hydrocodone-acetaminophen

.................................. 63, 64 hydrocodone-ibuprofen ...... 63 hydrocortisone .............. 30, 60 hydrocortisone ace-

pramoxine ......................... 9 hydrocortisone butyr lipo

base ................................. 30 hydrocortisone butyrate ..... 30 hydrocortisone valerate ...... 30 hydrocortisone-acetic acid .. 52 hydromorphone hcl ............ 64 hydroxychloroquine sulfate 94 hydroxyurea ........................ 87 hydroxyzine hcl ................... 66 HYDROXYZINE HCL .............. 81

hydroxyzine pamoate ......... 66 HYPERRAB S/D .................... 43 I ibandronate sodium ........... 61 IBRANCE .............................. 92 ibu ..........................................9 ibuprofen ...............................9 ICLUSIG ............................... 91 IDHIFA ................................. 92 ILARIS .................................. 44 ILARIS (150MG DELIVERED) 44 imatinib mesylate ............... 91 IMBRUVICA ......................... 91 IMFINZI ............................... 86 imipenem-cilastatin ............ 71 imipramine hcl .................... 81 imiquimod .......................... 23 IMOGAM RABIES-HT ........... 43 IMOVAX RABIES .................. 47 incassia ............................... 39 INCRELEX ............................ 40 indapamide ......................... 19 INFANRIX ............................ 47 INLYTA ................................ 91 INTELENCE .......................... 99 INTRALIPID ........................ 104 INTRAROSA ......................... 34 INTRON A .......................... 101 INTROVALE ......................... 34 INVANZ ............................... 71 INVEGA SUSTENNA ............. 96 INVEGA TRINZA................... 96 INVIRASE ........................... 102 INVOKAMET ...................... 109 INVOKAMET XR ................. 109 INVOKANA ........................ 109 IPOL .................................... 47 ipratropium bromide .......... 58 ipratropium-albuterol ........ 55 irbesartan ........................... 16 irbesartan-

hydrochlorothiazide ....... 19 IRESSA ................................. 91 ISENTRESS ........................... 98 ISENTRESS HD ..................... 98 isibloom .............................. 31 isoniazid .............................. 82 ISONIAZID ........................... 82 isosorbide dinitrate ............ 20 isosorbide dinitrate er ........ 20

isosorbide mononitrate ...... 20 isosorbide mononitrate er .. 20 itraconazole ........................ 84 ivermectin ........................... 93 IXIARO ................................. 47 J JAKAFI.................................. 91 JANTOVEN ......................... 106 JANUMET .......................... 112 JANUMET XR ............. 112, 113 JANUVIA ............................ 109 JENCYCLA ............................ 39 jevantique lo ....................... 35 jinteli ................................... 35 JOLESSA ............................... 35 JOLIVETTE ............................ 39 JULEBER ............................... 35 JULUCA .............................. 100 JUNEL 1.5/30 ....................... 35 JUNEL 1/20 .......................... 35 JUNEL FE 1.5/30 .................. 35 JUNEL FE 1/20 ..................... 35 JUXTAPID ............................. 18 K KADCYLA ............................. 88 KALETRA ............................ 102 KALYDECO ........................... 55 KARIVA ................................ 35 kcl in d5w lactated ringers 103 kcl in dextrose-nacl ........... 104 KELNOR 1/35 ....................... 35 ketoconazole ....................... 84 ketoprofen .......................... 65 ketorolac tromethamine ..... 51 KEYTRUDA ........................... 86 KIMIDESS ............................. 35 KINERET ............................... 45 KINRIX ................................. 48 kionex ................................ 103 KISQALI 200 DOSE ............... 92 KISQALI 400 DOSE ............... 92 KISQALI 600 DOSE ............... 92 KISQALI FEMARA 200 DOSE 93 KISQALI FEMARA 400 DOSE 93 KISQALI FEMARA 600 DOSE 93 klor-con ............................. 103 KLOR-CON ......................... 103 KLOR-CON 10 .................... 103 KLOR-CON M10 ................. 103 KLOR-CON M20 ................. 103

119

KLOR-CON SPRINKLE ......... 103 KORLYM............................. 110 KRISTALOSE ......................... 26 K-TAB ................................. 103 KURVELO ............................. 35 KUVAN ............................... 108 KYNAMRO ........................... 18 L labetalol hcl ......................... 12 LACRISERT ........................... 51 lactated ringers ................. 105 lactulose .............................. 26 lactulose encephalopathy ... 26 lamivudine......................... 100 lamivudine-zidovudine ...... 100 lamotrigine .......................... 77 lansoprazole ........................ 25 LANTUS .............................. 111 LANTUS SOLOSTAR ............ 111 LARIN 1.5/30 ....................... 35 LARIN 1/20 .......................... 35 LARIN FE 1.5/30................... 35 LARIN FE 1/20...................... 35 LARISSIA .............................. 35 LARTRUVO ..................... 86, 89 latanoprost .......................... 51 LATUDA ............................... 96 LAZANDA ............................. 64 LEENA .................................. 35 leflunomide ......................... 44 LENVIMA 10 MG DAILY DOSE

........................................ 91 LENVIMA 14 MG DAILY DOSE




........................................ 91 LENVIMA 8 MG DAILY DOSE 91 LESSINA ............................... 35 LETAIRIS ............................... 56 letrozole .............................. 90 leucovorin calcium .............. 89 LEUKERAN ........................... 85 LEUKINE ............................. 106 leuprolide acetate ............... 42 LEVALBUTEROL TARTRATE .. 59 LEVEMIR ............................ 111

LEVEMIR FLEXTOUCH ....... 111 levetiracetam...................... 78 levetiracetam in nacl .......... 78 levobunolol hcl ................... 50 levocetirizine dihydrochloride

........................................ 56 levofloxacin......................... 74 levofloxacin in d5w ............. 74 LEVONEST ........................... 35 levonorgest-eth estrad 91-day

........................................ 35 LEVONORGEST-ETH ESTRAD

91-DAY ............................ 35 LEVONORGESTREL-ETHINYL

ESTRAD ........................... 35 levonorg-eth estrad triphasic

........................................ 35 LEVORA 0.15/30 (28) .......... 36 levo-t................................... 41 levothyroxine sodium ......... 41 levothyroxine-liothyronine . 41 LEVOTHYROXINE-

LIOTHYRONINE ............... 41 LEVOXYL .............................. 41 LEXIVA ............................... 102 lidocaine ............................. 66 lidocaine hcl ........................ 66 lidocaine hcl (pf) ................. 66 lidocaine viscous ................. 66 lidocaine-prilocaine ............ 66 lillow ................................... 31 lincomycin hcl ..................... 68 lindane ................................ 94 linezolid .............................. 68 LINZESS ............................... 25 liothyronine sodium ........... 41 LIPODOX ............................. 89 LIPODOX 50 ........................ 89 liprozonepak ....................... 66 lisinopril .............................. 19 lisinopril-hydrochlorothiazide

........................................ 15 LITHIUM .............................. 21 lithium carbonate ............... 21 lithium carbonate er ........... 20 LONSURF ............................. 87 loperamide hcl .................... 24 LOPINAVIR-RITONAVIR ..... 102 lopreeza .............................. 31 lorazepam ........................... 67

LORCET ................................ 63 LORCET HD .......................... 64 LORCET PLUS ....................... 63 LORTAB ......................... 63, 64 LORYNA ............................... 36 losartan potassium ............. 16 losartan potassium-hctz...... 15 LOTEMAX ............................ 51 lovastatin ............................ 17 LOW-OGESTREL ................... 36 loxapine succinate .............. 95 LUMIGAN ............................ 51 LUMIZYME .......................... 55 LUPRON DEPOT (1-MONTH) 42 LUPRON DEPOT (3-MONTH) 42 LUPRON DEPOT (4-MONTH) 42 LUPRON DEPOT (6-MONTH) 42 LUPRON DEPOT-PED (1-

MONTH) .......................... 42 LUPRON DEPOT-PED (3-

MONTH) .......................... 42 LUTERA ................................ 36 LYNPARZA ........................... 88 LYRICA ................................. 76 LYRICA CR ............................ 76 LYSODREN ........................... 41 LYZA..................................... 39 M magnesium sulfate ............ 103 malathion ............................ 94 MAPROTILINE HCL .............. 78 MARLISSA ............................ 36 MARPLAN ............................ 79 MATULANE .......................... 85 MAVYRET .......................... 101 meclizine hcl ....................... 81 medroxyprogesterone acetate

........................................ 39 mefloquine hcl .................... 94 megestrol acetate ............... 39 MEKINIST............................. 91 meloxicam ........................... 65 memantine hcl .................... 21 MENACTRA.......................... 48 MENEST ............................... 36 MENOMUNE ....................... 48 MENVEO.............................. 48 mercaptopurine .................. 45 meropenem ........................ 71 mesalamine ......................... 60

120

mesna .................................. 88 MESNEX ............................... 88 MESTINON............................. 9 METADATE ER ..................... 53 metaproterenol sulfate ....... 59 metformin hcl ........... 109, 110 metformin hcl er ............... 109 methadone hcl .................... 64 methazolamide ............. 19, 50 methimazole ....................... 43 methotrexate ...................... 45 methotrexate sodium ... 45, 46 methotrexate sodium (pf) ... 45 methoxsalen rapid .............. 23 METHYCLOTHIAZIDE ........... 19 methylphenidate hcl ........... 54 methylphenidate hcl er . 53, 54 methylphenidate hcl er (cd) 53 methylprednisolone ............ 30 methylprednisolone sodium

succ ................................. 30 metipranolol ....................... 50 metoclopramide hcl ............ 24 metolazone ......................... 19 metoprolol succinate er ...... 12 metoprolol tartrate ............. 12 metoprolol-

hydrochlorothiazide ........ 15 metronidazole ..................... 69 metronidazole in nacl ......... 69 mexiletine hcl ...................... 17 MIACALCIN .......................... 61 MICROGESTIN 1.5/30 .......... 36 MICROGESTIN 1/20 ............. 36 MICROGESTIN FE 1.5/30 ..... 36 MICROGESTIN FE 1/20 ........ 36 midodrine hcl ...................... 16 miglustat ........................... 108 mili....................................... 36 mimvey ................................ 36 mimvey lo ............................ 36 MINITRAN ........................... 20 minocycline hcl ................... 75 minoxidil .............................. 20 mirtazapine ......................... 78 misoprostol ......................... 26 mitomycin ........................... 88 MITOMYCIN ........................ 88 mitoxantrone hcl ................. 89 M-M-R II .............................. 48

MODERIBA ........................ 101 moexipril hcl ....................... 20 moexipril-hydrochlorothiazide

........................................ 15 mometasone furoate..... 30, 57 mondoxyne nl ..................... 75 MONO-LINYAH ................... 36 MONONESSA ...................... 36 montelukast sodium ........... 58 MONUROL .......................... 69 morgidox ............................ 75 morphine sulfate ................ 64 MORPHINE SULFATE ...... 64, 65 morphine sulfate (pf) ......... 64 morphine sulfate er ............ 64 MOVANTIK .......................... 24 moxifloxacin hcl .................. 74 MOZOBIL .......................... 106 MULTAQ ............................. 17 mupirocin ........................... 69 mycophenolate mofetil ...... 46 mycophenolate mofetil hcl 46 mycophenolate sodium ...... 46 MYLOTARG ......................... 88 myorisan ............................. 23 MYRBETRIQ ........................ 27 myzilra ................................ 36 N nabumetone ....................... 65 nadolol ................................ 12 nafcillin sodium .................. 72 NAFCILLIN SODIUM ............ 72 NAGLAZYME ..................... 108 nalbuphine hcl .................... 64 naloxone hcl ....................... 62 naltrexone hcl ..................... 62 naproxen ............................ 65 naproxen dr ........................ 65 naproxen sodium ................ 65 naratriptan hcl .................... 10 NARCAN .............................. 62 NATACYN ............................ 84 nateglinide ........................ 110 NATPARA ............................ 61 NEBUPENT .......................... 94 NECON 0.5/35 (28) ............. 39 NECON 1/50 (28) ................ 36 NECON 7/7/7 ...................... 36 nefazodone hcl ................... 79 NEFAZODONE HCL .............. 79

neomycin sulfate................. 67 neomycin-bacitracin zn-

polymyx ........................... 49 neomycin-polymyxin-

dexameth ........................ 49 neomycin-polymyxin-

gramicidin ....................... 49 neomycin-polymyxin-hc ...... 52 NEOMYCIN-POLYMYXIN-HC 50 neo-polycin ......................... 51 neo-polycin hc ..................... 50 NERLYNX ............................. 91 NEULASTA ......................... 106 NEULASTA ONPRO ............ 106 NEUPOGEN ....................... 107 NEUPRO .............................. 11 nevirapine ........................... 99 NEVIRAPINE ........................ 99 nevirapine er ....................... 99 NEXAVAR ............................. 91 niacin er (antihyperlipidemic)

........................................ 18 nicardipine hcl ..................... 13 NICOTROL............................ 62 NICOTROL NS ...................... 62 nifedipine er ........................ 13 nifedipine er osmotic release

........................................ 13 NIKKI .................................... 36 nilutamide ........................... 85 nimodipine .......................... 14 NINLARO ............................. 88 NISOLDIPINE ER................... 14 NITRO-BID ........................... 20 nitrofurantoin ..................... 69 nitrofurantoin macrocrystal 69 nitrofurantoin monohyd

macro .............................. 69 nitroglycerin ........................ 20 NITROGLYCERIN .................. 20 nizatidine ............................ 25 NORA-BE ............................. 39 NORETHIN ACE-ETH ESTRAD-

FE..................................... 36 norethindrone ..................... 40 norethindrone acetate ........ 39 norethindrone acet-ethinyl

est ................................... 36 norethindrone-eth estradiol37 NORGESTIMATE-ETH

121

ESTRADIOL ...................... 37 norgestim-eth estrad triphasic

........................................ 37 NORLYDA ............................. 40 NORLYROC........................... 40 NORTHERA .......................... 16 NORTREL 0.5/35 (28) .......... 40 NORTREL 1/35 (21) ............. 37 NORTREL 1/35 (28) ............. 37 NORTREL 7/7/7 ................... 37 nortriptyline hcl .................. 81 NORTRIPTYLINE HCL ............ 81 NORVIR .............................. 102 novofine ............................ 111 novofine plus ..................... 112 NOVOLIN 70/30 ................. 112 NOVOLIN 70/30 RELION .... 112 NOVOLIN N ........................ 112 NOVOLIN N RELION ........... 112 NOVOLIN R ........................ 112 NOVOLIN R RELION ........... 112 NOVOLOG ......................... 112 NOVOLOG FLEXPEN .......... 112 NOVOLOG MIX 70/30 ........ 112 NOVOLOG MIX 70/30

FLEXPEN ........................ 112 NOVOLOG PENFILL ............ 112 novotwist .......................... 112 NOXAFIL .............................. 84 NP THYROID ........................ 41 NUEDEXTA ........................... 54 NULOJIX ............................... 46 NUPLAZID ............................ 96 nutrilipid ............................ 105 NUVARING .......................... 37 NYAMYC .............................. 84 NYATA ................................. 84 nystatin ............................... 84 nystatin-triamcinolone ........ 23 NYSTOP ............................... 84 O OCELLA ................................ 37 OCREVUS ............................. 53 octreotide acetate .............. 42 ODEFSEY ............................ 100 ODOMZO ............................. 91 OFEV .................................... 55 ofloxacin .............................. 74 okebo .................................. 75 olanzapine ........................... 96

olmesartan medoxomil ...... 16 olmesartan medoxomil-hctz16 olopatadine hcl ................... 49 omega-3-acid ethyl esters .. 18 omeprazole ......................... 25 OMNITROPE ....................... 40 ondansetron ....................... 82 ondansetron hcl.................. 82 ONFI .................................... 77 OPDIVO ............................... 86 OPSUMIT ............................ 56 oralone ............................... 22 ORENCIA ............................. 46 ORENCIA CLICKJECT ............ 46 ORFADIN ........................... 108 ORKAMBI ............................ 55 orphenadrine citrate er .... 113 ORSYTHIA ............................ 37 oseltamivir phosphate ........ 98 OSPHENA ............................ 37 OTEZLA ............................... 46 oxaliplatin ........................... 88 oxandrolone ....................... 32 oxaprozin ............................ 65 oxcarbazepine .................... 75 oxybutynin chloride ............ 27 oxybutynin chloride er ....... 27 oxycodone hcl ..................... 64 oxycodone-acetaminophen63,

64 oxymorphone hcl er ........... 65 P PACERONE .......................... 17 paclitaxel ............................ 88 paliperidone er ................... 96 palonosetron hcl ................. 82 PANCREAZE ....................... 108 PANRETIN ........................... 93 pantoprazole sodium.......... 26 paricalcitol .......................... 61 PARICALCITOL ..................... 61 paroex ................................. 22 paromomycin sulfate ......... 67 paroxetine hcl ................ 67, 80 paroxetine hcl er ................ 80 PASER .................................. 82 PAXIL ................................... 80 PEDIARIX ............................. 48 PEDVAX HIB ........................ 48 peg 3350/electrolytes ........ 26

peg 3350-kcl-na bicarb-nacl 26 peg-3350/electrolytes......... 26 PEGANONE .......................... 75 PEGASYS ............................ 101 PEGASYS PROCLICK ........... 101 penicillin g potassium ......... 72 penicillin v potassium ......... 73 PENTAM .............................. 94 PENTASA ............................. 60 pentoxifylline er .................. 15 PERIOGARD ......................... 22 PERJETA ............................... 88 permethrin .......................... 94 perphenazine ...................... 95 phenadoz ............................ 81 PHENADOZ .......................... 81 phenelzine sulfate ............... 79 PHENERGAN ........................ 81 phenobarbital ..................... 77 phenytoin ...................... 75, 76 phenytoin sodium ............... 76 phenytoin sodium extended

........................................ 76 PHILITH ................................ 40 PHOSPHOLINE IODIDE......... 50 pilocarpine hcl ..................... 22 pimozide ............................. 95 PIMTREA ............................. 37 pindolol ............................... 12 pioglitazone hcl ................. 110 pioglitazone hcl-glimepiride

...................................... 113 pioglitazone hcl-metformin

hcl .................................. 113 piperacillin sod-tazobactam so

........................................ 73 PIRMELLA 1/35 .................... 37 PIRMELLA 7/7/7 .................. 37 piroxicam ............................ 65 PLENAMINE ....................... 103 podofilox ............................. 23 polycin ................................. 51 polyethylene glycol 3350 .... 26 polymyxin b-trimethoprim.. 50 POMALYST........................... 85 PORTIA-28 ........................... 37 potassium chloride ... 103, 104 potassium chloride crys er 103 potassium chloride er ....... 103 potassium citrate er ............ 27

122

PRADAXA ........................... 106 pramipexole dihydrochloride

........................................ 11 prasugrel hcl ...................... 105 pravastatin sodium ............. 17 prazosin hcl ......................... 12 prednisolone ....................... 30 prednisolone acetate .......... 51 prednisolone sodium

phosphate ....................... 30 PREDNISOLONE SODIUM

PHOSPHATE ..................... 52 prednisone .................... 30, 31 PREDNISONE ....................... 30 PREDNISONE INTENSOL ...... 30 preferred plus insulin syringe

...................................... 112 PREFEST ............................... 37 PREMARIN ........................... 37 PREMPHASE ........................ 37 PREMPRO ............................ 37 PRENATAL ......................... 105 PREVALITE ........................... 18 PREVIFEM ............................ 37 PREZCOBIX ........................ 102 PREZISTA ........................... 102 PRIFTIN ................................ 82 PRIMAQUINE PHOSPHATE .. 94 primidone ............................ 77 PROAIR HFA ......................... 59 PROAIR RESPICLICK ............. 59 probenecid ............................ 9 prochlorperazine ................. 81 prochlorperazine edisylate . 95 prochlorperazine maleate ... 95 PROCRIT ............................ 107 PROCTOFOAM HC ............... 31 procto-med hc ..................... 60 PROCTO-PAK ....................... 31 PROCTOSOL HC ................... 60 PROCTOZONE-HC ................ 60 PROFENO ............................. 65 progesterone micronized .... 40 PROGLYCEM ...................... 110 PROGRAF ............................. 46 PROLASTIN-C ....................... 55 PROLIA ................................. 61 PROMACTA ....................... 107 promethazine hcl .......... 56, 81 promethegan ...................... 81

PROMETHEGAN .................. 81 propafenone hcl ................. 17 propranolol hcl ................... 12 PROPRANOLOL HCL ............ 12 propranolol hcl er ............... 12 PROPRANOLOL-HCTZ .......... 15 propylthiouracil .................. 43 PROQUAD ........................... 48 protriptyline hcl .................. 81 PROVENTIL HFA .................. 59 PRUDOXIN .......................... 23 PULMICORT FLEXHALER ..... 58 PULMOZYME ...................... 56 PURIXAN ............................. 87 pyrazinamide ...................... 82 pyridostigmine bromide ........9 Q QUADRACEL ........................ 48 QUASENSE .......................... 38 quetiapine fumarate........... 96 quinapril hcl ........................ 20 quinapril-hydrochlorothiazide

........................................ 15 quinidine gluconate er........ 17 quinidine sulfate ................. 17 quinine sulfate .................... 94 QVAR .................................. 58 QVAR REDIHALER ............... 58 R RABAVERT ........................... 48 rabeprazole sodium ............ 26 raloxifene hcl ...................... 31 ramipril ............................... 20 RANEXA............................... 15 ranitidine hcl ....................... 25 RAPAMUNE ......................... 46 rasagiline mesylate ............. 11 RAVICTI ............................. 108 REBIF ................................... 53 REBIF REBIDOSE .................. 53 REBIF REBIDOSE TITRATION

PACK ............................... 53 REBIF TITRATION PACK ....... 53 RECLIPSEN ........................... 38 RECOMBIVAX HB ................ 48 regenecare ha ..................... 66 REGRANEX .......................... 23 relador pak ......................... 66 RELENZA DISKHALER ........... 98 reli-on insulin syringe ....... 112

RELISTOR ............................. 24 REMICADE ........................... 46 REMODULIN ........................ 56 repaglinide ........................ 110 repaglinide-metformin hcl 113 REPATHA ............................. 18 REPATHA PUSHTRONEX

SYSTEM ........................... 15 REPATHA SURECLICK ........... 18 RESCRIPTOR ........................ 99 RESTASIS ............................. 51 RESTASIS MULTIDOSE ......... 51 RETACRIT ........................... 107 RETROVIR .......................... 100 REVLIMID ...................... 85, 89 REXULTI ............................... 96 REYATAZ ............................ 102 RIBASPHERE ...................... 101 ribavirin ....................... 55, 101 RIDAURA ............................. 44 rifabutin .............................. 82 rifampin ............................... 82 RIFATER ............................... 82 riluzole ................................ 55 rimantadine hcl ................... 98 risedronate sodium ............. 61 RISPERDAL CONSTA ............ 96 risperidone .......................... 97 risperidone m-tab ............... 96 ritonavir ............................ 102 RITUXAN .............................. 86 rivastigmine ........................ 21 rivastigmine tartrate ........... 21 rizatriptan benzoate ........... 10 ropinirole hcl ....................... 11 rosadan ............................... 69 rosuvastatin calcium ........... 17 ROTARIX .............................. 48 ROTATEQ ............................. 48 ROWEEPRA.......................... 78 ROZEREM ............................ 22 RUBRACA............................. 90 RYDAPT ............................... 92 S SABRIL ................................. 77 SANDIMMUNE .................... 46 SANTYL ................................ 23 SAPHRIS ............................... 97 scopolamine ........................ 81 selegiline hcl ........................ 11

123

selenium sulfide .................. 24 SELZENTRY ......................... 101 SENSIPAR ............................. 41 SEREVENT DISKUS ............... 59 sertraline hcl ....................... 80 SETLAKIN ............................. 38 sevelamer carbonate .......... 27 SHAROBEL ........................... 40 SHINGRIX ............................. 48 SIGNIFOR ............................. 42 sildenafil citrate .................. 56 silver sulfadiazine ................ 74 SIMBRINZA .......................... 50 simvastatin .......................... 17 sirolimus .............................. 46 SIRTURO .............................. 82 SKLICE .................................. 94 sodium chloride ................ 104 sodium phenylbutyrate ...... 27,

108 sodium polystyrene sulfonate

...................................... 104 SOLTAMOX .......................... 86 SOLU-MEDROL .................... 31 SOMATULINE DEPOT ........... 42 SOMAVERT .......................... 42 SORINE ................................ 17 sotalol hcl ............................ 17 sotalol hcl (af) ...................... 17 SPIRIVA HANDIHALER.......... 58 SPIRIVA RESPIMAT .............. 58 spironolactone .................... 19 spironolactone-hctz ............ 15 SPORANOX .......................... 84 SPRINTEC 28 ........................ 38 SPRITAM .............................. 78 SPRYCEL ............................... 92 SPS ..................................... 104 SRONYX ............................... 38 SSD ...................................... 74 stavudine ........................... 100 STIOLTO RESPIMAT ............. 55 STIVARGA ............................ 92 STRENSIQ .......................... 108 STREPTOMYCIN SULFATE .... 67 STRIBILD .............................. 99 SUBOXONE .......................... 62 sucralfate ............................ 27 sulfacetamide sodium ......... 74 SULFACETAMIDE SODIUM .. 74

SULFADIAZINE..................... 74 sulfamethoxazole-

trimethoprim .................. 74 SULFAMETHOXAZOLE-

TRIMETHOPRIM .............. 74 sulfasalazine ....................... 60 sulindac ............................... 65 SUMATRIPTAN .................... 10 sumatriptan succinate ........ 10 sumatriptan succinate refill 10 SUPRAX ............................... 71 SUSTIVA .............................. 99 SUTENT ............................... 92 SYEDA ................................. 38 SYLATRON ......................... 101 SYLVANT ............................. 44 SYMBICORT ......................... 55 SYMDEKO ............................ 56 SYMFI ................................ 100 SYMFI LO ........................... 100 SYMLINPEN 120 ................ 110 SYMLINPEN 60 .................. 110 SYNAGIS .............................. 43 SYNAREL ............................. 42 SYNERCID ............................ 68 SYNRIBO .............................. 90 SYNTHROID ......................... 41 SYPRINE ............................ 104 T TABLOID .............................. 87 tacrolimus ...................... 24, 46 tadalafil (pah) ..................... 56 TAFINLAR ............................ 92 TAGRISSO ............................ 92 TAMIFLU ............................. 98 tamoxifen citrate ................ 86 tamsulosin hcl ..................... 27 TARCEVA ............................. 92 TARGRETIN ......................... 93 TARINA FE 1/20 .................. 38 TASIGNA ............................. 92 tazarotene .......................... 24 TAZICEF ............................... 71 TAZORAC............................. 24 TAZTIA XT ............................ 14 TECENTRIQ .......................... 86 TECHNIVIE ......................... 101 TEFLARO ............................. 71 temazepam ......................... 21 TENIVAC .............................. 48

tenofovir disoproxil fumarate ...................................... 100

terazosin hcl ........................ 27 terbinafine hcl ..................... 84 terbutaline sulfate .............. 59 terconazole ......................... 84 testosterone cypionate ....... 32 testosterone enanthate ...... 32 TETANUS-DIPHTHERIA

TOXOIDS TD .................... 48 tetrabenazine ...................... 55 THALOMID .......................... 85 theophylline er .................... 60 thioridazine hcl ................... 95 THIOTEPA ............................ 85 thiothixene .......................... 95 THYMOGLOBULIN ............... 43 tiagabine hcl ........................ 77 tigecycline ........................... 69 TILIA FE ................................ 38 timolol maleate ................... 50 TIMOLOL MALEATE ............. 13 TIVICAY ................................ 99 tizanidine hcl ......................... 9 TOBI PODHALER .................. 56 TOBRADEX ........................... 67 tobramycin .................... 67, 68 tobramycin sulfate .............. 68 tobramycin-dexamethasone

........................................ 50 TOLBUTAMIDE .................. 110 tolcapone ............................ 11 tolterodine tartrate ............. 28 tolterodine tartrate er ........ 27 topiramate .......................... 77 toposar ................................ 93 topotecan hcl ...................... 93 torsemide ............................ 19 tpn electrolytes ................. 105 TRACLEER ............................ 56 TRADJENTA ....................... 110 tramadol hcl ........................ 64 tramadol hcl er .................... 65 tranexamic acid ................. 106 tranylcypromine sulfate ...... 79 TRAVATAN Z ........................ 51 trazodone hcl ...................... 79 TREANDA ............................. 88 TRECATOR ........................... 82 tretinoin ........................ 24, 93

124

TRI FEMYNOR ...................... 38 triamcinolone acetonide .... 22,

31 TRIAMCINOLONE ACETONIDE

........................................ 31 triamterene-hctz ................. 15 triazolam ............................. 66 triderm ................................ 31 TRIDERM ............................. 31 TRIENTINE HCL .................. 105 TRI-ESTARYLLA .................... 38 trifluoperazine hcl ............... 95 trifluridine ........................... 98 trihexyphenidyl hcl .............. 11 triklo .................................... 18 TRI-LEGEST FE ...................... 38 TRI-LINYAH .......................... 38 TRILYTE ................................ 26 trimethoprim....................... 69 tri-mili .................................. 38 trimipramine maleate ......... 81 TRINESSA (28) ..................... 38 TRINTELLIX .......................... 80 TRI-PREVIFEM ..................... 38 TRISENOX ............................ 88 TRI-SPRINTEC ...................... 38 TRIUMEQ ........................... 101 TRIVORA (28) ....................... 38 tri-vylibra ............................. 38 trospium chloride ................ 28 trospium chloride er ........... 28 TRUMENBA ......................... 48 TRUVADA .......................... 100 TUDORZA PRESSAIR ............ 58 TWINRIX .............................. 48 TYBOST .............................. 101 TYKERB ................................ 92 TYMLOS ............................... 61 TYPHIM VI ........................... 48 TYSABRI ............................... 53 U ULORIC .................................. 9 UNITHROID .......................... 41 UPTRAVI ........................ 15, 16 ursodiol ............................... 24 UVADEX ............................... 24 V valacyclovir hcl .................... 98 VALCHLOR ........................... 85 valganciclovir hcl ................. 97

valproate sodium ................ 77 valproic acid ........................ 77 valsartan ............................. 16 valsartan-hydrochlorothiazide

........................................ 15 vancomycin hcl ................... 69 VANDAZOLE ........................ 69 VAQTA ................................ 49 VARIVAX ............................. 49 VARIZIG ............................... 49 VASCEPA ............................. 18 VELCADE ............................. 89 VELIVET ............................... 38 VENCLEXTA ......................... 89 VENCLEXTA STARTING PACK

........................................ 89 venlafaxine hcl .................... 80 venlafaxine hcl er ............... 80 VENTAVIS ............................ 56 VENTOLIN HFA .................... 59 verapamil hcl ...................... 14 verapamil hcl er .................. 14 VERSACLOZ ......................... 97 VERZENIO ........................... 93 VESICARE ............................ 28 VESTURA ............................. 38 VICTOZA ............................ 110 VIDEX ................................ 100 VIDEX EC ............................. 99 VIEKIRA PAK ...................... 101 VIEKIRA XR ........................ 102 VIENVA................................ 38 vigabatrin ............................ 77 vigadrone ............................ 77 VIIBRYD ............................... 80 VIIBRYD STARTER PACK ...... 80 VIMPAT ............................... 76 viorele ................................. 38 VIRACEPT .......................... 102 VIRAMUNE .......................... 99 VIREAD .............................. 100 voriconazole ....................... 84 VOTRIENT ........................... 92 VPRIV ................................ 108 VRAYLAR ............................. 97 VYFEMLA ............................ 40 vylibra ................................. 38 VYVANSE ............................. 54 VYXEOS ............................... 89

W warfarin sodium ................ 106 WELCHOL ............................ 18 WERA .................................. 40 X XALKORI .............................. 92 XARELTO ............................ 106 XARELTO STARTER PACK ... 106 XATMEP ............................... 46 XELJANZ ............................... 46 XELJANZ XR ......................... 46 XERMELO ............................ 24 XGEVA ................................. 61 XIFAXAN .............................. 69 XIGDUO XR ........................ 110 XIIDRA ................................. 52 XOLAIR ................................ 55 XTANDI ................................ 85 xulane .................................. 39 XYREM ................................. 22 Y YERVOY ............................... 90 YF-VAX ................................. 49 YONDELIS ............................ 85 YONSA ................................. 85 YUVAFEM ............................ 39 Z zafirlukast ............................ 58 zaleplon ............................... 21 ZARAH ................................. 39 ZARXIO .............................. 107 zebutal ................................ 63 ZEJULA ................................. 89 ZELBORAF ............................ 92 zenatane ............................. 24 ZENATANE ........................... 24 ZENCHENT ........................... 40 ZENZEDI ............................... 54 ZERIT ................................. 100 zidovudine ......................... 100 zileuton er ........................... 58 ziprasidone hcl .................... 97 ZIRGAN ................................ 97 zoledronic acid .................... 61 ZOLINZA .............................. 93 zolmitriptan......................... 10 zolpidem tartrate ................ 22 zolpidem tartrate er ............ 22 zonisamide .......................... 76 ZORTRESS ...................... 46, 47

125

ZOSTAVAX ........................... 49 ZOVIA 1/35E (28) ................. 39 ZOVIRAX .............................. 98

ZYDELIG .............................. 93 ZYKADIA .............................. 92 ZYPREXA RELPREVV ............ 97

zytiga ................................... 85 ZYTIGA ................................. 85

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If you believe that Presbyterian Healthcare Services has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance. You can file a grievance in person, or by mail, fax, or email. If you need help filing a grievance, the Privacy Officer and Civil Rights Coordinator is available to help you.

Presbyterian Privacy Officer and Civil Rights Coordinator P.O. Box 27489 Albuquerque, NM 87125 Phone: 1-866-977-3021, TTY: 711 Fax: 505-923-5124 Email: [email protected]

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201 Phone: 1-800-368-1019, 1-800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

http://www.hhs.gov/ocr/office/file/index.html

Y0055_MPC081640_SPAN_Aceptado_08222016

Aviso de no discriminación y accesibilidad La discriminación es contra la ley

Presbyterian Health Services (Presbyterian) cumple con todas las leyes de derechos civiles federales aplicables y no discrimina sobre la base de la raza, color, nacionalidad, edad, discapacidad o sexo. Presbyterian no excluye a las personas ni las trata de manera diferente en base a la raza, color, nacionalidad, edad, discapacidad o sexo.

Presbyterian:

• brinda ayudas y servicios gratuitos a personas con discapacidades para que se comuniquen efectivamente con nosotros, como intérpretes calificados de lenguaje de señas e información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos)

• brinda servicios de idioma gratuito a personas cuyo idioma principal no es el inglés, como intérpretes calificados e información escrita en otros idiomas

Si necesita estos servicios, comuníquese con el Centro de servicio al miembro de Presbyterian llamando al 505-923-5420, 1-855-592-7737, TTY: 711. Si cree que Presbyterian no le ha brindado estos servicios o lo ha discriminado en otra manera en base a la raza, color, nacionalidad, edad, discapacidad o sexo, puede presentar una queja llamando al Oficial de privacidad de Presbyterian y Coordinadora de derechos civiles, P.O. Box 27489, Albuquerque, NM, 87125, o llame al 1-866-977-3021, TTY: 711, fax 505-923-5124 o [email protected]. Puede presentar una queja en persona o por correo, correo electrónico, o a los números de teléfono anteriores. Si necesita ayuda para presentar una queja, llame al 1-866-977-3021 y un representante del cliente le ayudará. También puede presentar una queja a la Oficina de Derechos Civiles del Departamento de Salud y Servicios Humanos de los EE.UU. electrónicamente a través del portal de quejas de la Oficina de Derechos Civiles en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o por correo o teléfono a:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Línea telefónica gratis: 1-800-368-1019, 1-800-537-7697 (TDD) Los formularios de quejas están disponibles en http://www.hhs.gov/ocr/office/file/index.html.

English ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 505-923-5420, 1-855-592-7737 (TTY: 711).

Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 505-923-5420, 1-855-592-7737 (TTY: 711).

Navajo D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 505-923-5420, 1-855-592-7737 (TTY: 711).

Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 505-923-5420, 1-855-592-7737 (TTY: 711).

German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 505-923-5420, 1-855-592-7737 (TTY: 711).

Chinese 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 505-923-5420，1-855-592-7737 (TTY: 711)。

Arabic ملحوظة: إذا كنت تتحدث اذكراللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم: 505-923-5420، .(TTY: 711) 7737-592-855-1 رقم هاتف الصم والبكم

Korean 주의 : 한국어를 사용하시는 경우 , 언어 지원 서비스를 무료로 이용하실 수 있습니다 . 505-923-5420, 1-855-592-7737 (TTY: 711) 번으로 전화해 주십시오 .

Tagalog- Filipino

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 505-923-5420, 1-855-592-7737 (TTY: 711).

Japanese 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。505-923-5420、1-855-592-7737 (TTY: 711) まで、お電話にてご連絡ください。

French ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 505-923-5420, 1-855-592-7737 (ATS: 711).

Italian ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 505-923-5420, 1-855-592-7737 (TTY: 711).

Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 505-923-5420, 1-855-592-7737 (телетайп: 711).

Hindi ध्यान दें: ्दद आप दिदंी बोलत ेिैं तो आपके ललए मुफत में भयाषया सिया्तया सेवयाएं उपलब्ध िैं। 505-923-5420, 1-855-592-7737 (TTY: 711) पर कॉल करें।

Farsi توجه: اگر به زبان فارسی گفتگو می کنيد، تسھيالت زبانی بصورت رايگان برای شما فراھم می باشد. با 1-855-592-7737 ،505-923-5420 (TTY: 711) تماس بگيريد.

Thai เรยีน: ถา้คณุพดูภาษาไทยคณุสามารถใชบ้รกิารชว่ยเหลอืทางภาษาไดฟ้ร ีโทร 505-923-5420, 1-855-592-7737 (TTY: 711).


Multi-Language Interpreter Services

Presbyterian Senior Care (HMO) Presbyterian SeniorCare (HMO-POS) Presbyterian MedicarePPO

Este formulario de medicamentos se actualizó el 23 de octubre de 2018. Esta información está disponible de forma gratuita en otros idiomas. Para información más reciente o si tiene otras preguntas, póngase en contacto con el Centro de Servicio al Cliente de Presbyterian al (505) 923-6060 o al 1-800-797-5343 (TTY: 711).

Desde el 1 de octubre hasta el 14 de febrero, el horario de atención es de 8 a. m. a 8 p. m, los siete días de la semana. Desde el 15 de febrero hasta el 30 de septiembre, el horario de atención es de 8 a. m. a 8 p. m, de lunes a viernes. Cerramos los días festivos.

También puede visitar nuestro sitio web en www.phs.org/Medicare.

Presbyterian existe para mejorar la salud de los pacientes, de sus afiliados y de las comunidades a los que brindamos servicio.

www.phs.org/Medicare



formulario de medicamentos del año 2018 (lista de...

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